CMH Home Medical Equipment

CMH Home Medical Equipment

Wound Care Order Form

Patient Name: Date of Birth:

Ordering Physician: Dx:

Dressing #1 ; Number per day ; Primary or Secondary

Dressing #2 ; Number per day ; Primary or Secondary

Dressing #3 ; Number per day ; Primary or Secondary

Dressing #4 ; Number per day ; Primary or Secondary

Dressing #5 ; Number per day ; Primary or Secondary

The above named patient needs the surgical dressings noted above for the prescribed treatment of:

[ ] A wound caused by, or treated by, a surgical procedure; or

[ ] Debridement of a wound that is medically necessary

Size of wounds: #1 x ; #2 x ; #3 x ; #4 x ; #5 x

Please list the size of any additional wounds that are being treated: #1 x ; #2 x

Substitute items (if needed)

Expected length of dressings:

I certify that this patient’s condition is being monitored on a monthly basis.

Physician’s Signature: Date:

CMH Home Medical Equipment

Wound Care Order Form

Item / 1 Week / 2 Weeks / 4 Weeks
Hollister
509338 – Restore Contact Layer 4” x 5 “
509394 – Restore LITE Foam 4” x 5”
509345 – Restore LITE Foam Silver – 4” x 5”
Systagenix
MA028 – Prisma 28 cm x 4.34”
PG004 – Promogran 28cm x 4.34”
Convatec
177902 – Aquacel 4” x 4”
403765 – Aquacel AG 4” x 5”
403770 – Aquacel AG Hydrofiber ribbon 3/8 x 18”
420128 – Aquacel AG Hydrofiber ribbon .39” x 18”
187660 Duoderm 4 x 4
Safetac Technology/Moinlycke Health Care
287100 – Mepilex AG 4” x 4”
1443 – Tubigrip size C
1447 – Tubigrip size D
1434 – Tubigrip size E
1438 – Tubigrip size F
Kendall
8884433500 – Xeroform 4” x 4”
Miscellaneous
2084 – Coban 4”
6715 – Kerlix 4 ½” x 4.1 YD
2733 – 4” x 4” Gauze
1806 – 2” x 2” Gauze
001582 – Saline Wound Wash
30222100 – Drawtex 4 x 4
31332100 Drawtex – 6 x 8
Medipore Tape
2862 – H tape 2” x 10 yd
2864 – 4”
2962 – 2” x 10 yd
2963 – 3” x 10 yd
2966 – 6”