Consumables prescription and order form

1. Person’s details

• Select scheme or program

  Lifetime Care

  Workers Care

• Name

  Select
• Address
  Address

• Contact name (for deliveries)

• Contact phone

• Date of injury

  Date

• Age

Injury

• TBI

• SCI

• Level

• ASIA score

2. Order Information

• This prescription is a

  Discharge prescription

  New/revised prescription

  Amendment to an existing order

• Order start date

  Date

• Order end date

  Date

• Next review date

  Date

3. Identification of need

• Injury related condition requiring consumable products (e.g. neurogenic bladder, renal calculi, stoma sites, pressure areas, pre-existing stress or urge incontinence, functional incontinence, dysphagia)

4. Continence

• 4.1 Current bowel management (frequency, assistance required, equipment and medications currently used)

• 4.2 Recommended bowel management (frequency, assistance required, additional equipment needed, changes in medications)

• 4.3 Current bladder management (frequency, assistance required, equipment and medications currently used)

• 4.4 Recommended bladder management (frequency, assistance required, additional equipment needed, changes in medications)

5. Skin integrity

• 5.1 Current management if skin integrity including any current wounds (frequency, assistance required, products currently used)

• 5.2 Recommended management of skin integrity (frequency, assistance required, products needed)

6. Respiratory

• 6.1 Current respiratory consumable management (what consumables are used e.g. nebuliser)

• 6.2 Recommended respiratory consumable management (what consumables are needed)

7. Nutrition

• 7.1 Does the person require nutritional supplements?

• 7.2 Does the person require a dietician review?

• 7.3 Current nutritional consumables required

• 7.4 Recommended nutritional consumables

8. Other consumable products

• 8.1 Current management

• 8.2 Recommended management

9. Additional information

• If you are recommending products that are not included in the BrightSky product list, or the quantity is above what is recommended, please provide justification below

10. Prescription

Continence Products

• BrightSky product code

• Description

• Quantity / Units

• Frequency

Skin Integrity Products

• BrightSky product code

• Description

• Quantity / Units

• Frequency

Respiratory Products

• BrightSky product code

• Description

• Quantity / Units

• Frequency

Nutritional Products

• BrightSky product code

• Description

• Quantity / Units

• Frequency

Other Products

• BrightSky product code

• Description

• Quantity / Units

• Frequency

• 10.1 Required delivery cycle

  Monthly

  3-monthly

  6-monthly

  12-monthly

  Other

• Specify

• - Please note that a delivery cycle of less than one month can only be requested if storage problems exist
  - Please note that the supplier will make forward ordering arrangements according to the selected delivery cycle

• Contact BrightSky on 1300 88 66 01 or icarecc@brightsky.com.au, if additional equipment is required before the delivery date

11. Attachments

• Reports/documents attached (please list any reports or documents such as quotes including with this request)

  Yes

  No

Attachments

• Document

  Media

12. Prescriber declaration

• I declare that the person named above, requires the requested consumable products, to manage their injury-related continence, respiratory, nutritional and skin integrity needs.
  This prescription has been developed in consultation with the person named above in collaboration with their family member or nominated person if necessary. All people involved in conversations with this prescription agree with it.

• Name

• Signature

  Sign
• Address
  Address

• Qualification

• Phone

• Days/hours available

• Date

  Date

• Email