Full Name NHS Number Date of Birth: Address GP Name and surgery Wound description Post-op Frequency of dressing (circle as appropriate) Leg ulcer- arterial / venous change Diabetic foot ulcer Change dressing Laceration every............................days Pressure Sore Other: please specify Please note the number of dressings requested should Is the dressing on the reflect the change frequency and the wound healing rates. South & West Devon Formulary - yes or no and Name of dressing, bandages, tape Size Quantity if no give a rationale for and preparation use 1 2 3 4 5 6 7 8 Requested Community Practitioner: Care Home Staff ( Nursing and by Practitioners name Residential): Signature Nurses name Designation Signature Date Designation Telephone number Date Comments / Message Collection of prescriptions. Please tick the box with the preferred delivery option Pharmacy for delivery to patient Collected by Patient//Relative Other (please specify) Please note it is essential all relevant information is completed on this form to prevent any delays in generating a prescription. To be kept for one year.
Full Name NHS Number Date of Birth: Address GP Name and surgery Wound description (circle as appropriate) Post-op Leg ulcer- arterial / venous Diabetic foot ulcer Laceration Pressure Sore Other: please specify Frequency of dressing change Change dressing every............................days Please note the number of dressings requested should reflect the change frequency and the wound healing rates. Is the dressing on the South & West Devon Formulary - yes or no and if no give a rationale for use Name of dressing, bandages, tape and preparation Size Quantity 1 2 3 4 5 6 7 8 Requested by Community Practitioner: Practitioners name Signature Designation Date Telephone number Care Home Staff ( Nursing and Residential): Nurses name Signature Designation Date Comments / Message Collection of prescriptions. Please tick the box with the preferred delivery option Pharmacy for delivery to patient Collected by Patient//Relative Other (please specify) Please note it is essential all relevant information is completed on this form to prevent any delays in generating a prescription. To be kept for one year.