Requestor detailsName * REQUIRED Designation * REQUIRED Place of work * REQUIREDTelephone * REQUIRED Email * REQUIRED Patient detailsNHS number * REQUIRED Date of birth * REQUIRED Postcode * REQUIRED GP * REQUIRED Wound DetailsType of wound * REQUIREDSkin tear/lacerationSurgicalPressure UlcerVenous UlcerArterial UlcerDiabetic UlcerOtherWound Bed Description * REQUIREDEpithelialisingGranulatingSloughyCritically ColonisedInfectedNecroticFungatingWound Depth * REQUIREDSuperficialShallowCavityDeep cavitySinusExudate levels * REQUIREDDryMinimalModerateHeavyDate wound occurred (if known) DD slash MM slash YYYY Aim of treatment is to provide: * REQUIREDProtectionWarm moist environmentRehydrationDesloughingAbsorptionOdour controlAnti-microbial effectFormulary DetailsPlease tell us about any formulary products used to date, the duration of use and reason they were discontinued or not suitable.Formulary product informationPlease state which formulary product or products are being requested and the rationale for this.Non Formulary DetailsPlease tell us about the non-formulary product you propose to useTVN to advise Yes No Section BreakCAPTCHA