Ostomy/Urinary Cath V1 (Mar 2017) Retention Period: 30 days from data entry date 1 of 2

Week(s)

Qty Max Qty Code Max

2/MO

2/MO SOS-0025 5/WK2/MO SOS-0026 5/WK2/MO SOS-0027 5/WK2/MO SOS-0028 5/WK2/MO SOS-0029 5/WK2/MO SOS-0030 5/WK2/MO SOS-0031 5/WK2/MO SOS-0032 5/WK2/MO SOS-0033 5/WK2/MO SOS-0034 5/WK2/MO2/MO SOS-0035 5/WK

SUR-0030 2/MO SOS-0036 5/WK2/MO2/MO SOS-0037 5/WK2/MO SOS-0038 5/WK2/MO SOS-0039 5/WK2/MO SOS-0040 5/WK

35/WK SOS-0041 5/WK35/WK SOS-0042 5/WK35/WK SOS-0043 5/WK35/WK SOS-0044 5/WK

SOS-0045 5/WK

1/WK SOS-0046 5/WK1/WK1/WK SOS-0047 5/WK

2/MO SOS-0048 5/WK2/MO SOS-0049 5/WK

SOS-0050 5/WK2/MO SOS-0051 5/WK2/MO SOS-0052 5/WK2/MO SOS-0053 5/WK

2/MO

SOS-0065 1/Pt

MedlineMedlineMedlineMedlineMedline

10mLBalloon10mLBalloon10mLBalloon

Red Flat Cut-to-Fit Coupling/Flange 50mm (2")

Product Description Brand Size

As per policy, CCAC approval must be obtained PRIOR to submitting form if any of the following are applicable to this order:1) Quantities exceed maximums; 2) Non-regular delivery type for active patients; or 3) Specialty items as identified with: "(‡)"

CCAC Approver Name: Rationale:

Code Product Description Brand SizeURINARY SUPPLIESFOLEY CATHETERS

SUR-0001 2 Way Hydrogel Coated Latex 12Fr BARD Can 5mL Balloon

Delivery Time: Regular Delivery URBAN (Next Day) Regular Delivery RURAL (< 48 Hrs)

OSTOMY SUPPLIES & ACCESSORIES

Ostomy Skin Barriers for 2 Piece System-SenSura Mio Click (Coloplast)

Same Day URBAN (‡) Same Day RURAL (‡) Weekend URBAN (‡) Weekend RURAL (‡)

MAXIMUM FOR OSTOMY FLANGES AND BAGS IS 10/PATIENT/ADMISSION

Next Day RURAL(‡)

Immediate Delivery URBAN (‡)

Frequency: Q: Delivery To: Patient Pick-Up at Depot (Specify Depot ): Patient Private-Pay Home Delivery

Order Type: New Admission Frequency Change Change in Orders Renewal:

Health Card # (optional) Patient Contact Phone Number and Address

MEDICAL SUPPLIES ORDER FORM - OSTOMY / URINARY CATHETERS

CCAC Patient Surname CCAC Patient First Name CCAC Client # or BRN #

SUR-0015 2 Way Hydrogel Coated Latex 16Fr 30mLBalloon

SUR-0004 2 Way Hydrogel Coated Latex 18Fr BARD Can 5mL BalloonSUR-0014 2 Way Hydrogel Coated Latex 14Fr BARD Can 30mLBalloon

BARD Can

INTERMITTENT CATHETERSSUR-0112

2 Way Hydrogel Coated Latex 18Fr2 Way Hydrogel Coated Latex 20Fr

2 Way 100% Silicone 12 Fr2 Way 100% Silicone 14Fr 2 Way 100% Silicone 16Fr2 Way 100% Silicone 18Fr2 Way 100% Silicone 16Fr2 Way 100% Silicone 18Fr2 Way 100% Silicone 20Fr

Female Intermittent Catheter 10 Fr

SUR-0029

SUR-0032

BARD CanBARD Can 30mLBalloon

30mLBalloon

10mLBalloon30mLBalloon30mLBalloon30mLBalloon

MedlineMedline

URINARY LEG BAGS

SpeediCath 10 Fr x 9 cmSUR-0113SUR-0114SUR-0115

Female Intermittent Catheter 12 FrFemale Intermittent Catheter 14 Fr

SpeediCath SpeediCath SpeediCath

12 Fr x 9 cm14 Fr x 9 cm12-18 Fr 30cmMale Intermittent Catheter 12-18 Fr

Medline 19oz/600mLSUR-0086SUR-0089

SUR-0090SUR-0094

MedlineMedline

MedlineMedline

Leg Bag Twist Valve w/StrapsLeg Bag Twist Valve w/StrapsDrainage Bag w/Anti-Reflux Tower & Metal Drain ClampUrinary Leg Bag Extention Tubing

Pouch Convex Deep Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8")

Yellow Flat Cut-to-Fit Coupling/Flange 70mm (2 3/4")Green Convex Light Cut-to-Fit Coupling/Flange 40mm (1 9/16")Red Convex Light Cut-to-Fit Coupling/Flange 50mm (2")Blue Convex Light Cut-to-Fit Coupling/Flange 60mm (2 3/8")

StatLockStatLockStatLock

StatLock

19oz/600mL32oz/1100mL

Yellow Convex Light Cut-to-Fit Coupling/Flange 70mm (2 3/4")

Universal Foley Cath StabilizationUniversal Plus Cath Stabilization-LUniversal Plus Cath Stabilization-M

Universal Plus Cath Stabilization-S

SUR-0085

SenSura Mio Click Green Coupling/Flange 40mm (1 9/16")SenSura Mio Click Red Coupling/Flange 50mm (2")SenSura Mio Click Blue Coupling/Flange 60mm (2 3/8")SenSura Mio Click Yellow Coupling/Flange 70mm (2 3/4")One Piece Urostomy System-SenSura Mio (Coloplast)Pouch Convex Light Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8")Pouch Convex Light Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4")Pouch Convex Light Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4")

Green Convex Deep Cut-to-Fit Coupling/Flange 40mm (1 9/16")Red Convex Deep Cut-to-Fit Coupling/Flange 50mm (2")Blue Convex Deep Cut-to-Fit Coupling/Flange 60mm (2 3/8")Yellow Convex Deep Cut-to-Fit Coupling/Flange 70mm (2 3/4")

Urostomy Pouches for 2 Piece System (Coloplast)SenSura Mio Click Green Coupling/Flange 40mm (1 9/16")

Drainable Pouches for 2 Piece System (Coloplast)SenSura Mio Click Red Coupling/Flange 50mm (2")

Pouch Convex Deep Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4")

Pouch Convex Deep Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4")

Pouch Flat Cut-to-Fit Stoma Size 10-55mm (3/8"-1 1/8")

Pouch Convex Light Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8")

One Piece System with Drainable Pouches-SenSura Mio (Coloplast)

Pouch Convex Light Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4")

Pouch Convex Light Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4")

Leg Bag Kit Twist Valve w/Straps & 18"Tubing

2000 mL18 inches

Each12-14 Fr10-12 Fr

6- 8.5 Fr

CATHETER STABILIZATIONSUR-0111SUR-0104

Pouch Convex Deep Cut-to-Fit Stoma Size 10-23mm (3/8"-7/8")Pouch Convex Deep Cut-to-Fit Stoma Size 15-33mm (5/8"-1 1/4")Pouch Convex Deep Cut-to-Fit Stoma Size 10-43mm (3/8"-1 3/4")SUR-0105

SUR-0106 OSTOMY KIT (Coloplast)

Ostomy Care Kit (1/Pt admission)For further NE CCAC medical supplies information always refer to the most updated medical supplies list on the NE CCAC website.

SUR-0117 2 Way Red Latex Tiemann Coude Tip BARD Can 5 mL 16 Fr

SUR-0118 2 Way 100% Silicone Coude Tip Medline 10 mL 14 Fr

SUR-0033SUR-0034

SUR-0016SUR-0017

SUR-0027SUR-0028

SUR-0002 2 Way Hydrogel Coated Latex 14Fr BARD Can 5mL BalloonSUR-0003 2 Way Hydrogel Coated Latex 16Fr BARD Can 5mL Balloon

SUR-0119 2 Way 100% Silicone Coude Tip Medline 10 mL 16 Fr

SUR-0116 2 Way Red Latex Tiemann Coude Tip BARD Can 5 mL 14 Fr

Ostomy/Urinary Cath V1 (Mar 2017) Retention Period: 30 days from data entry date 2 of 2

Health Card # (optional) Patient Contact Phone Number and Address

CCAC Patient Surname CCAC Patient First Name CCAC Client # or BRN #

Qty Max Qty Code Max

2/MO SOS-0054 1/Pt

1/WK SOS-0055 1/Pt

SOS-0056 1/Pt

2/MO SOS-0057 3/WK

1/WK SOS-0058 1/Pt

7/WK SOS-0059 1/Pt

7/WK SOS-0066 1/WK

2/MO

2/MO SOS-0060 5/WK

2/WK SOS-0061 1/WK

SOS-0062 1/WK

SOS-0063 1/WK

SOS-0064 1/WK

Support Belt-SenSura Mio-Standard Brava Belt up to 100cm

Support Belt-SenSura Mio-XXL Brava Belt up to 135cm

Protective Sheet Brava

57g (2 oz)

10x10 cm

Brava

Foley Catheter Tray MED-Rx

Sudbury Branch 705-523-4829

I understand incomplete forms or forms submitted without required approval will not be processed and will be returned for follow-up (Sign below: )Date Ordered: Ordered By:

DD/MM/YYYY Nurse or Care Coordinator Name, Designation and Organization Name

Fax to CCAC Branch: Kirkland Lake Branch 1-855-697-7358

Sault Ste. Marie Branch 705-949-3844

North Bay Branch 705-474-2369 Parry Sound Branch 705-773-4056

Timmins Branch 705-267-7957

16 inch

SUR-0108 Specimen Container Simport 90 mL

60 mL

3.6 g pouch

Code Product Description Brand Size Product Description Brand Size

Sterile Lubricant Water Based

Drainage Tube Universal 1 way

Medline

MED-Rx

BD

Medline

SourceMuko

MED-Rx

SUR-0078

SUR-0080

SUR-0110

SUR-0120

SUR-0091

Brava

Powder (Bottle) Brava

Fistula & Wound Pouch (‡) Eakin

Paste (Tube)

Mouldable Skin Barrier Ring BravaThe following items require approval from the NE CCAC Enterostomal Therapy Nurse:

60 mL 60 g (2 oz)

25 g (1 oz)

4.2mm thick

245x160mm

60 mL 2oz tip

SUR-0079

Skin Barrier Ring Small (‡) Eakin Cohes 50mm (2")

Skin Barrier Ring Large (‡) Eakin Cohes 100mm (4")

Antimicrobial Ostomy Ring (‡) Hydrofera Blue 60mm (2.5")

Ceramide Skin Barrier Ring (‡) Adapt CeraRing 48mm (2")

Strip Paste

SUR-0103

Cath Plus & Drain Tube Cover Set

Irrigation Tray Kit with Piston Syringe

Syringe Catheter Tip

Bulb Irrigation Syringe

URINARY KITS

OTHER MEDICAL SUPPLIES (as per the NE CCAC Medical Supplies List)

SMK-0008 Percutaneous Nephrostomy KitCATHETER ACCESSORIES

OSTOMY ACCESSORIES

Please refer to the most recent NE CCAC Regional Medical Supplies List for additional supplies which can be found on the NE CCAC website:

http://healthcareathome.ca/northeast/en/Partners/forms-and-resources

OTHER INFORMATION