Requestor detailsName*Designation*Place of work*Telephone*Email* Patient detailsNHS number*Date of birth*Postcode*GP*Wound DetailsType of wound*Skin tear/lacerationSurgicalPressure UlcerVenous UlcerArterial UlcerDiabetic UlcerOtherWound Bed Description*EpithelialisingGranulatingSloughyCritically ColonisedInfectedNecroticFungatingWound Depth*SuperficialShallowCavityDeep cavitySinusExudate levels*DryMinimalModerateHeavyDate wound occurred (if known) Aim of treatment is to provide:*ProtectionWarm moist environmentRehydrationDesloughingAbsorptionOdour controlAnti-microbial effectOtherYou selected 'other'. Please tell us more:*Formulary 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 CAPTCHA