Provision of Lymphoedema
Compression Garments
Prescription/Order Form
Queensland Health and Non-Queensland Health Providers
Eligible patients are able to receive Queensland Health funded compression garments under the
Queensland Health Guideline, Guideline for Compression Garments for Adults with Malignancy Related
Lymphoedema: Eligibility, Supply and Costing. Patients are eligible for two garments every six months per
affected body part. ONLY ONE custom garment to be ordered in the first instance and when fitted, clinically
assessed as suitable then to order the second.
All prescribers should prescribe ready-to-wear garments as a first preference, where the clinician considers
the ready-to-wear option to provide the same or better treatment effect to a custom made garment.
Providers must provide scripts that are current. Supply does not cover prophylactic or travel garments. All
orders for ready-to-wear garments are to be placed on the order form (Attachment 1). If ordering more than
one garment i(i.e. sleeve and glove) separate order forms are required.
Where clinical indications or limb size fall outside of the ready to wear range provided, custom made
garments may be ordered. Written quotation for cost and supplier of the garment must be attached to the
order form. Custom made garments can be ordered from the order form (Attachment 2). ONLY ONE
custom garment will be ordered in the first instance and when fitted, if clinically assessed as suitable then
another garment can be ordered.
Prescribing Therapist
Therapist Name: insert
Hours of work: insert
Practice Name: insert
Email: insert
Address: insert
Telephone: insert
Mobile: insert
Fax: insert
Date of referral: insert
Referred by:
Patient Details
Name: insert
DOB: insert
Address: insert
Sex: M/F
Telephone: insert
Email: insert
Mobile: insert
Eligibility Criteria
Place a cross in
the box if Yes*
Has the patient been diagnosed with malignancy related lymphoedema?
Is the patient over the age of 16 years old?
Is the patient a permanent resident of Queensland? (Residential address on Centrelink
Pension card or Centrelink Health Care Card must be Queensland)?
Does the patient hold a Centrelink Pensioner Card or Centrelink Health Care Card?
Card Number: insert
The Queensland Health Order Form provides a checklist of eligibility criteria. The
provider is required to sight the cards, provide card numbers, declare eligibility of the
patient (i.e. the patient holds a Centrelink pension card or health care card and is eligible
for Medicare) against the criteria on the order form and provide a photocopy of both
sides of the applicant’s concession card.
Is the patient eligible for Medicare?
Card Number: insert
Delivery Instructions (The health facility will post the garment to the prescriber)
insert
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Declaration
Completed prescription/order form to be provided from a practitioner who works for Queensland Health or a
non-governmental community service organisation e.g. Bluecare or a private practitioner.
The form is to be completed by the prescribing therapist.
I confirm that my signature below represents:
Place a cross in
the box if Yes*
My agreement that the information can be used to assess eligibility for a Lymphoedema
Garment within the Guideline for Compression Garments for Adults with Malignancy
Related Lymphoedema: Eligibility, Supply and Costing.
I acknowledge that the Hospital and Health Service may require more information or a
review of information.
The information that I have supplied on this application is true and correct to the best of
my knowledge.
My understanding is that this application is not a formal approval or guarantee of service.
Queensland Health Practitioners
I am a physiotherapist or occupational therapist registered with Australian Health Practitioner
Regulation Agency (AHPRA) and hold a Level 1 lymphoedema training certificate accredited by
the Australasian Lymphology Association (ALA) or eligibility to register on the National
Lymphoedema Practitioner Register (NLPR) as category one, with recency of practice by
demonstration of clinical experience in compression garment prescription within the previous two
years and continued professional development of 50 points in the previous two years as set out
in the ALA Lymphoedema Continuing Professional Development program set out by the NLRP
OR
I am a physiotherapist or occupational therapist registered with Australian Health Practitioner
Regulation Agency (AHPRA) and have completed the Compression garment, selection, fitting
and monitoring education resource as part of the statewide compression garment trial.
Non-governmental community service organisation or a private practitioner eligibility
criteria.
I am a physiotherapist, occupational therapist, podiatrist, registered nurse or medical doctor
registered with the Australian Health Practitioner Regulation Agency (AHPRA) and hold a Level
1 lymphoedema training certificate accredited by the Australasian Lymphology Association
(ALA),with recency of practice by demonstration of clinical experience in compression garment
prescription within the previous two years and continued professional development of 50 points
in the previous two years as set out in the ALA Lymphoedema Continuing Professional
Development program set out by the National Lymphoedema Practitioner Register
I am responsible for the outcome of the prescription and the duty of care to the patient.
Signature: _____________________________
Name: insert
Designation: insert
(e.g. Occupational Therapist/Physiotherapist)
Date: insert
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Attachment 1: Order Form Ready-to-Wear Garments
Patient Name:
Patient DOB:
Ready-to-wear Compression Garment
Order form
Therapist Name:
Therapist contact details for garment query:
Select one or more options from each category below after careful review of products available from the manufacturer.
Only available options can be ordered.
When ordering multiple garments ( e.g. sleeve and glove) a separate order form will be required (*Add garment order
code)
Manufacturer
Lower Limb
Upper Limb
Style of garment
Size
Length
Compression
JOBST
(FAMMIS vendor:
Smith & Nephew
– 100887)
Garment order
code………………
 FOR MEN
 RELIEF
 ULCER CARE
 ULTRASHEER
 ELVAREX
 ELVAREX
 BELLA LITE
 BELLA
STRONG
LOWER LIMB





 CI 1
 Cl 2
 Cl 3
MEDI
(FAMMMIS
vendor supply via
Reis – 108598)
Garment order
code
………………….
 DUOMED
 FORTE
 PLUS
 ELEGANCE
 ULCER







SIGVARIS
(FAMMIS vendor:
Morris Medical 378828)
Garment order
code……………..
 COTTON
 COMFORT CF
 MAGIC
 TOP FINE
 TRADITIONAL
503/ 504
MEDICAL
STOCKINGS
(FAMMIS vendor:
Medical Stockings
-420061 )
Garment order
code.………
 THERAFIRM
WOMEN
 THERAFIRM
MEN
 KNEE HIGH (A-D)
 THIGH HIGH (A-F)
 THIGH HIGH (A-G)
 CHAP STYLE
 PANTY HOSE (A-T)
X-SMALL
SMALL
MEDIUM
LARGE
X-LARGE

AD
AG
AF
AT
CH
CG
AG
 HARMONY
 ESPRIT
 ADVANCE
 TRADITIONAL
UPPER LIMB
 SLEEVE (C-G)
 COMBINED
SLEEVE AND
GAUNTLET (A-G)
 GLOVE
 GAUNTLET
ADDITIONS
HADDENHAM
(FAMMIS vendor:
Haddenham –
343542)
Garment order
code ....................
 PERTEX Light
 Pertex 2
 Pertex 3
BIOMET
(FAMMIS vendor:
Biomet - 100985)
Garment order
code………….
 VENOSAN 6000
 VENOSAN 4000
 VENOSAN 5000
 VENOSAN 7000
 VENOSAN 4000
 VENOSAN 2000
 VENOSAN 7000
PERTEX Light
Pertex 2 (glove
only)







1
2
3
4
5
6
7
WIDTH
 X-WIDE
 PLUS
 Normal
LENGTH
 OPEN TOE
 CLOSED TOE
 SHORT
 LEFT
 NORMAL
 RIGHT
 PETITE
 GRIP TOP LONG
 SHOULDER CAP
 BODY STRAP
 OTHER
………………………...
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ORTHO
APPLIANCES
(FAMMIS vendor:
Orthopaedic
Appliances 147831)
Garment order
code………….
 OFA
BAMBERG
PRIUS
(FAMMIS vendor
Prius - 366081)
Garment order
code………….
 ELLIPSIS PRO
 ELLIPSIS
THERAPY
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Attachment 2: Custom Made Compression Garment
Patient Name:
Patient DOB:
Custom-made
compression garment
Therapist Name:
Therapist contact details for garment query:
ORDER FORM
1. PROVIDE RATIONALE (tick all those which apply and provide details)
Custom garment style/ configuration
Style required:
required.
Does not fit into ready-to-wear size
compression garments
Circle the measurement points requiring custom sizing:
 UL: A, B, C, D, E, F, G
 LL: A, B, C, D, E, F, G
Compression level required is not
available in ready-to-wear
garments
Compression level required:
Other reason (Specify)
2. PROVIDE GARMENT DETAILS
Supplier
Garment description
Garment quote*
Freight cost
Total cost
* Written quotation for cost and supplier of the garment must be attached to the order form.
3. ATTACH RELEVANT MEASUREMENT FORMS
These forms are changed frequently and should be obtained from the supplier directly. Custom
garments available via the QH SOA742 include those in the Table 1 on the following page.
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4. COMPLETE DECLARATION
I confirm that I have assessed the following:
The patient will be able to don and doff the garment
The patient has committed to wearing the garment as prescribed
The patient has agreed to attend appointments for garment fitting/monitoring as required
I confirm I have appropriate training to measure custom compression garments
Therapist Signature: ………………………………………………………………………….……………………
Therapist Name: …………………………………………………………………………………………………....
Date: …………………………………………………………………………………………………………………
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(Affix identification label or enter details)
Family name:
Given name(s):
Custom-made
compression garment
Address:
Date of birth:
Sex:
M
F
Table 1: Suppliers of custom-made compression garments on SOA742
Distributor
Range of garments
Contact details
Biomet
Venosan
PO Box 348
North Ryde, NSW 1670
Ph: 02 9978 6100
Fax: 02 9878 6473
Email: au.orders@biomet.com
Morris Medical
Sigvaris
P.O. Box 3286
Newmarket, QLD 4051
Ph: 07 3356 6995
Fax: 07 3356 6990
Orthopaedic
Appliances
OFA Bamberg
55 Tinning Street
Brunswick, VIC 3056
Ph: 03 9383 1622
Fax 03 9383 1644
*Note custom garments need to be measured at
Goodwill Orthopaedics
http://www.goodwillortho.com.au/index.php
Reis Orthopaedic &
Surgical
Medi
25 John Street
Lidcombe, NSW 2141
Ph: 02 9643 1444
Fax: 02 9643 1264
Smith and Nephew
Elvarex,
Jobskin,
Jobst
PO Box 242
Mount Waverley, VIC 3149
Ph: 13 13 60
Fax: 1800 671 000
email: order.aus@smith-nephew.com
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