Form Page | Gloucestershire Health and Care NHS Foundation Trust

Requestor details

Name *

Designation *

Place of work *

Telephone *

Email *

NHS number *

Date of birth *

Postcode *

GP *

Type of wound *

Wound Bed Description *

Wound Depth *

Exudate levels *

Date wound occurred (if known)

Aim of treatment is to provide: *

You selected 'other'. Please tell us more: *

Please tell us about any formulary products used to date, the duration of use and reason they were discontinued or not suitable.

Formulary product information

Please state which formulary product or products are being requested and the rationale for this.

Please tell us about the non-formulary product you propose to use

TVN to advise

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