Continence Aids
This prescription is for 12 months. (For re-order every 3 months)
This prescription is for a once only order
Please complete all sections
1a. Client Details
Client ID: / Is the applicant an existing DEP client? / Yes / No / Unsure
1b. Further Client Details
CRN
(Pension No.): / A DEP Application Form is required for all new applicants, and existing clients whose situation has changed or requires confirmation (Special Consideration)
Surname: / Given Names:
Preferred Phone: / Mobile:
Email: / Date of Birth: / /
Residential Address
(Delivery to be made to):
Postal Address (if different):
Parent/Guardian (if applicable):
Contact Details (if different):
Client Diagnosis and Details of Functional Disability:
LEVEL OF CARE (if in residential care facility):
If client resides in a Residential care facility please enter their RCS 1-8. (1-4 high level of care -not eligible for DEP. 5-8 low level of care – eligible for DEP)
2. Identification of Need/Clinical Criteria
Please ‘check’ as relevant:
Client has a permanent moderate to severe incontinence; AND
Equipment needs greater than would be covered by the Continence Aids Payment Scheme (CAPS) funding for clients eligible for CAPS; OR
Client is not eligible for CAPS.
3. Equipment Recommendation
CODE / Contract item* / PRODUCT / SUPPLIER / PER / QTY / QTY
*Denotes product on contract and must purchase product from nominated contractor (supplier)
PADS
2-piece anatomical shaped pads / Packs per Carton / Single / Box
168 323 0 / * / Moliform Extra (Blue) / 4 x 30 Ctn 120
168 810 / NO /
Moliform for Men (Grey )
11504280 / * / Euron Flex Super / McN / 4 x 28 Ctn 11211506280 / * /
Euron Flex Extra Plus
/ McN / 4 x 28 Ctn 11211508280 / * / Euron Flex Super Plus / McN / 4 x 28 Ctn 112
11509280 / NO /
Flex Maxi plus
/ McN / 4 x 28 Ctn 11258254 /
Tena Comfort Plus (Blue)
/ 4 x 20 Ctn 8058256 /
Tena Comfort Extra (Yellow)
/ 4 x 20 Ctn 8058255 /
Tena Comfort Super (Green)
/ 4 x 20 Ctn 80All in One / Packs per Carton / Single / Box
14522280 / OPADS006 / * / Euron Form Extra (medium) / McN / 3 x 28 Ctn 84
14532280 / * / Euron Form Extra (large) / McN / 4 x 28 Ctn 112
14506140 / * / Euron Form Extra Plus (x-small) / McN / 14 x12 Ctn 168
14516140 / NO / Euron Form Extra Plus (small) / 8 x 14 Ctn 112
14526280 / * / Euron Form Extra Plus (medium) / McN / 3 x 28 Ctn 84
14536280 / OPADS007 / Euron Form Extra Plus (large) / McN / 3 x 28 Ctn 84
14546140 / NO / Euron Form Extra Plus (x-large) / 14 x 4 Ctn 56
14518140 / * / Euron Form Super Plus (small) / McN / 8 x 14 Ctn 112
14528280 / * / Euron Form Super Plus (medium) / McN / 3 x 28 Ctn 84
14538280 / * / Euron Form Super Plus (large) / McN / 2 x 28 Ctn 56
14548140 / Euron Form Super Plus (x-large) / 4 x 14 Ctn 56
169448 / Molicare Premium Soft Extra (small) / 3 x 30 Ctn 90
169470 / Molicare Super Plus (small) / 4 x 14 Ctn 56
169670 / Molicare Super Plus (medium) / 4 x 14 Ctn 56
169870 / Molicare Super Plus (large) / 4 x 14 Ctn 56
Light Incontinence pads / Packs per Carton / Single / Box
10506140 / OPADS002 / * / Euron Micro Super (bulk pack) / McN / 12 x 28 Ctn 336
10106280 / OPADS003 / * / Euron Micro Extra Plus (bulk pack) / McN / 12 x 28 Ctn 336
10108280 / * / Euron Micro Super Plus (bulk pack) / McN / 12 x 28 Ctn 336
168540
/ /Molimed Comfort Ex Classic (Midi)
/ /6 x 28 Ctn 168
168570
/ / Molimed Comfort Ex Classic (Maxi) / / 6 x 28 Ctn 1681485208
/ / Molimed Couch Lt Med 25 gram / / 4 x 56 Ctn 224760503
/ / Tena Lady Extra / / 6 x 60 Ctn 120757730
/ / Tena Lady Super / / 6 x 30 Ctn 1802171236 / Tena Shields Super / Ctn 250
Bed pads / Packs per Carton / Single / Box
4865 / UNDER001 / * / Absorb Underpad 8 ply (Blueys) / RDH / Ctn 250
Pullup pants / Packs per Carton / Single / Box
13014140 / * / Euron Mobi (small) / McN / 8 x 14 Ctn 112
13024140 / * / Euron Mobi (medium) / McN / 8 x 14 Ctn 112
13034140 / Euron Mobi (large) / McN / 8 x 14 Ctn 112
13036140 / Euron Mobi Extra Plus (large) / McN / 8 x 14 Ctn 112
791002 / Tena Pants (small) / 4 x 15 Ctn 56
PADS: Pullup pants Continued / Packs per Carton
795200 / 4 x 12 Ctn 48
795300 / 4 x 10 Ctn 40
915871 / Molicare Mobile Super (small) / 4 x 14 Ctn 56
915872 / Molicare Mobile Super (medium) / 4 x 14 Ctn 56
915831 / Molicare Mobile (small) / 4 x14 Ctn 56
915832 / Molicare Mobile (medium) / 4 x14 Ctn 56
915861 / Molicare Mobile Light (small) / 4 x14 Ctn 56
915852 / Molicare Mobile Light (medium) / 4 x14 Ctn 56
NAPPIES
Unit / Single / Box
2421 – boy
2422 – girl / Huggies Crawler (medium) – boy
Huggies Crawler (medium) – girl / Ctn 120
2301 – boy
2302 – girl / Huggies Toddler (large) – boy
Huggies Toddler (large) – girl / Ctn 96
2308 – boy
2309 – girl / Huggies Walker (x-large) – boy
Huggies Walker (x-large) – girl / Ctn 88
2423 – boy
2424 – girl / Huggies Junior Nappies – boy
Huggies Junior Nappies – girl / Ctn 80
Ctn 120
KC2612 – boy
KC2613 – girl / Pull-Ups No.2 Training Pants – boy
Pull-Ups No.2 Training Pants – girl / Ctn 102
KC2614-90 – boy
KC2615-90 – girl / Pull-Ups No.3 Training Pants – boy
Pull-Ups No.3 Training Pants – girl / Ctn 90
KC2616-90 – boy
KC2617-90 – girl / Pull-Ups No.4 Training Pants – boy
Pull-Ups No.4 Training Pants – girl / Ctn 78
KC21495-90 – boy
KC21496-90 – girl / Drynites PJ Pants (size 4)
(4-7yrs 20-30kgs) – boy
Drynites PJ Pants (size 4)
(4-7yrs 20-30kgs) – girl / Ctn 64
KC21499-90 – boy
KC21511-90 – girl / Drynites PJ Pants (size 5.5)
(8-15yrs 27-57kgs) – boy
Drynites PJ Pants (size 5.5)
(8-15yrs 27-57kgs) – girl / Ctn 52
CATHETERS
Intermittent catheters / Unit / Single / box
CAT011-14-020-C / Indoplas (nelaton) 14fg –female / TSS / Ctn 250
001-12-040 -- CATHS019 / Indoplas (nelaton) 12fg 40cm male length / RDH / Singles
Indwelling catheters / Unit / Single / box
2265 / Bard Biocath Male fg / Box 10
2269 / Bard Biocath Female fg
28762 / 28764 /
28766 / 28768 / Releen Male CH 10mL Balloon / Box 5
28782 / 28784 /
28786 / 28788 / Releen Female CH 10mL Balloon / Box 5
1032-16 / Supracath Fr 10cc Balloon / Box 10
1032-18 / Supracath Fr 10cc Balloon / Box 10
URIDOMES
Unit / Single / box
5221 / NO / Uridome Conveen Security Plus
Self-adhesive / Box 30
5225 / NO / Uridome Conveen 25mm Self-adhesive Non-latex / Box 30
5230 / NO / Uridome Conveen 30mm Self-adhesive Non-latex / Box 30
5235 / NO / Uridome Conveen 35mm Self-adhesive Non-latex / Box 30
5240 / NO / Uridome Conveen 40mm Self-adhesive / Box 30
33301 / 33302 / 33303 / 33304 / Rochester Silicone Ultraflex 25/29/32/36mm / Box 30
Uridomes Continued / Unit / Single / box
36301 / 36302 / 36303 / 36304 / Rochester Silicone Wide Band 25/29/32/36mm / Box 30
32301/ 32302/32303/ 32304 / Rochester Silicone Pop On 25/29/32/36mm / Box 30
BAGS
Drainage bags overnight & leg / Unit / Single / box
340802 / Simpla O/N Bags S4 with tap (sterile) / Box 100
331107 / Simpla O/N Bags S3 with tap / Box 150
210171 / Conveen Short tube 25cm Leg bag 750mL (sterile) / Box 10
210181 / Conveen Long Tube 50cm Leg Bag 750mL (sterile) / Box 10
370901 / NO / Simpla Trident Long Tube Leg Bag 750mL (sterile) / Box 10
370899 / NO / Simpla Trident Short tube Leg Bag 750mL (sterile) / Sgl / box 20
6349 / Delux Leg Strap Kit (small) / Single
6350 / Delux Leg Strap Kit (large) / Single
9032 / Urocare Latex Leg Bag (large) / Single
9044 / Urocare Latex Leg Bag (extra large) / Single
7001 / Quick Drain Clamp / Single
5100 / Urofoam strips- single sided / Box 50
ICW4104-E / Drainage Bottle 4L with valve, tubing, lid / Pk 5
MISCELLANEOUS
Retention pants / Unit / Single / box
754300 / TENA Fix (x small) / Sgl/pkt 25
754400 / TENA Fix (small) / Pkt 25
754500 / TENA Fix (medium) / Sgl/pkt 25
754600 / TENA Fix (large) / Sgl/pkt 25
754700 / TENA Fix (x large) / Sgl/pkt 25
754800 / TENA Fix (xx large) / Sgl/pkt 25
PEH947711 3 / * / Molipants Comfort 1 (small) / McN / Box 25
PEH947712 2 / * / Molipants Comfort 1 (medium) / McN / Box 25
PEH947713 2 / * / Molipants Comfort 1 (large) / McN / Box 25
PEH947714 2 / * /
Molipants Comfort 1 (x large)
/ McN / Box 25PEH947744 3 / * /
Molipants Comfort 1 (xx large)
/ Box 25PEH 947730 / * /
Molipants Economy (medium)
/ Box 100PEH 947731 / * /
Molipants Economy (large)
/ McN / Box 100Gloves / Unit
GLOVE024 / * / Gloves (small) / RDH / Pkt 100
GLOVE025 / * / Gloves (medium) / RDH / Pkt 100
GLOVE026 / * / Gloves (large) / RDH / Pkt 100
GLOVE015 (non latex) / * / Gloves (Large) (non sterile & powder free) / RDH / Pkt 100
GLOVE016 (non latex) / * / Gloves (Medium) ( non sterile & powder free) / RDH / Pkt 100
GLOVE017 (non latex) / * / Gloves (small) ( non sterile & powder free) / RDH / Pkt 100
GLOVE023 (non latex) / * / Gloves (ex-large) ( non sterile & powder free) / RDH / Pkt 100
Other / Unit / Single / box
RDH Pharmacy S230292 / KY Gel / Lubricating Gel / Pharm / Tube
RDH Pharmacy / PDI Lube Gel Sachets / Box 144
4000 / Skin Bond Cement / Single
RDH Pharmacy ASC448C / Xylocaine / Lignocaine Syringe / Pharm / Single
6009 / Urocare Tubing Connector 5/16ths / Single
6010 / Urocare Tubing Connector 3/8ths / Single
ICW6060-E / Extension Tubing for 4L drainage bottle / Pk 5
7002 / Urosol 500mL / Sgl / Ctn 12
006 / Multigate Catheter Pack / Ctn 60
4. Prescriber Details
4 Print and sign to complete
Prescriber Name: / Approved Prescriber No.:
Qualification: / Email:
Work Unit: / Contact Number:
I declare that I am an Approved Prescriber of the appropriate level to prescribe this equipment according to the DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers.
OR
I declare that I have completed this prescription which has been endorsed by an Approved Prescriber of an appropriate level to prescribe this equipment, according to DEP Clinical Guidelines and DEP Professional Criteria for Approved Prescribers.
Signature: / Date: /
5. Endorsement (As required)
Endorsed by Approved Prescriber Name:
Approved Prescriber No.: / Qualification:
Work Unit: / Contact Number:
Email:
I endorse this prescription which has been completed by the above Approved Prescriber and acknowledge that all necessary assessments and clinical considerations have been completed and that the prescription is appropriate to the client.
Signature: / Date: /
DEP Clinical Approval (Office use only)
Approved Prescriber registration confirmed? Yes No If No, contact prescriber
AP Number format: DEP Admin Number - Level and Equip Type – Level and Equip Type eg. 52-G1SPMW-G2V
Approved / Not Approved
If not approved, provide brief rationale:
Name: / Title:
Signature: / Date: /
Completed forms should be faxed, posted or emailed to:
Darwin
(includes Darwin rural area)
F: 08 8945 9251
E:
A: PO Box 40596,
Casuarina NT 0811 / Central Australia
(includes Alice Springs, Remote Barkly)
F: 08 8951 6789
E:
A: PO Box 721,
Alice Springs NT 0871 / Top End Remote
(includes Katherine, East Arnhem)
F: 08 8945 9251
E:
A: PO Box 40596,
Casuarina NT 0811
DEP P-12 Continence Aids Created: March 2013 | Review: March 2014
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