NURSING HOME PRESCRIPTION REQUEST FOR WOUND
CARE PRODUCTS ( version 3 July 2014)
To Doctor................................at....................................................Practice
Date................................
From Nurse.............................at...........................................Nursing Home
Tel...................................
Patient’s name ………………………..
Date of Birth ……………
Price range per dressing
(dependent upon size)
Formulary Dressing
Wound type…………………………
Dressing Type
Size
No.
requested
Frequency
of change
Foam
Allevyn Plus Adhesive Sacrum
Allevyn Gentle Border including
sacral & heel
£4.87 - £7.04
Allevyn Gentle
£1.26 - £6.68
Foam
Aquacel Foam Adhesive
£1.37 - £ 9.96
Foam
Aquacel Foam Non-Adhesive
Aquacel Extra
5 x 5, 10 x10, 15 x 15 ,4x10, 4x20 & ,
4 x 30cm sizes
£1.33 - £6.88
Foam
£0.99 - £4.44
Hydrofiber®
Aquacel Ribbon
£1.81 - £2.42
Hydrofiber®
Actilite
£0.57 - £1.90
Honey (antimicrobial)
Algivon
£1.98 - £3.40
Honey (antimicrobial)
Atrauman Ag
Aquacel Ag Extra
20x30cm dressing is expensive
£0.51 - £2.43
Silver (antimicrobial)
£1.95 - £21.71
Silver (antimicrobial)
Aquacel Ag ribbon
£3.06 - 4.67
Silver (antimicrobial)
Atrauman
Silflex
35x60cm dressing is expensive
Biatain Super Adhesive (formerly
Alione)
Biatain Super Non-Adhesive
(formerly Alione)
£0.26 - £1.71
Low/Non-Adherent
£1.11 - £39.54
Atraumatic silicone film
£2.15 - £ 6.67
Hydrocapillary
£2.15 - £ 6.67
Hydrocapillary
Aquaform 15g
£2.02
Carboflex
£3.15 - £7.17
CliniSorb
Cavilon No Sting Barrier Film 1ml
Foam applicator
28ml pump spray
Durable barrier cream 20 x 2g sachet
£1.86 - £3.99
Hydrogel 15g
Carbon (odour
management)
Carbon (odour
management)
£4.96 - £7.47
Skin Protectant
Cosmopor E
£0.08 – £0.77
Post-Op
OpSite Post-Op
£0.85 - £3.24
Post-Op
Clearfilm
Comfeel Plus Transparent
5 x 7cm & square dressings only
£0.25 - £1.15
Vapour permeable film
£0.66 - £3.34
Hydrocolloid
Comfeel Plus Ulcer
£0.94 - £7.41
Hydrocolloid
DuoDERM Extra Thin
£0.75 - £3.89
Hydrocolloid
DuoDERM Signal
£2.10 - £7.32
Hydrocolloid
Eclypse
£0.73 - £8.15
Absorbent
Xupad
£0.15 - £0.40
Absorbent
Sorbsan flat/ribbon/packing
£0.81 - £3.47
Alginate
Foam
£1.48 - £9.59
If you are requesting a non-formulary product, please give details here of dressing, size, quantity, estimated
frequency of change and reason why a formulary product is unsuitable. Continue on another sheet if needed.
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Prices correct from the Drug Tariff, July 2014. This facsimile transmission is STRICTLY CONFIDENTIAL and intended only for
the person or organisation to which it is addressed. It may contain privileged and confidential information. If you have received
this facsimile in error, please notify the sender as soon as possible.
Written by: LC Sahlman
Checked By: I Gratrix
Medicines Management Team July 2014
NURSING HOME PRESCRIPTION REQUESTS FOR
WOUND CARE PRODUCTS
Supporting Information
(Version 3 July 2014)
This version of the wound care products request form has been updated to
reflect current pricing and recent formulary changes. Please note that:
Mesorb has been replaced by Xupad.
Biatain Foam and Versiva XC Hydrofibre dressings have been
replaced by Aquacel brand products.
Alione is now called Biatain Super
Wirral GPs have been notified and will expect requests for dressings from
Nursing Homes to be submitted using this form.
This form should be used for all Nursing Home requests for dressings with
immediate effect. Please complete all sections of the form.
The dressings listed on this form reflect the current formulary choices and
are expected to be suitable for the vast majority of wounds.
Always choose the most cost-effective dressing that is suitable for the
wound you are dressing.
Non-formulary dressings
The dressings listed overleaf will be suitable for the vast majority of wounds
and should always be considered as first and second choices. If you need to
request a non-formulary dressing for a patient, please ensure that it is a
cost-effective choice. You must also supply supporting information to
GP surgeries alongside your request so the GP is aware of the reasons why
a formulary choice is not appropriate. This will be documented in the
patient’s notes. Please ensure that all Nursing Home staff involved in
requesting prescriptions are aware of this form.
Please note: Treatment may be delayed if this request system is not
used.
Queries, including clinical advice should be directed to the Tissue Viability Service (0151
643 5330), or the Medicines Management Team (Tel 0151 643 5319)
Written by: LC Sahlman
Checked By: I Gratrix
Medicines Management Team July 2014