Negative Pressure Wound Therapy Application Form
Provide the patient and wound details needed to evaluate and prepare negative pressure wound therapy treatment.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Wound Assessment
Wound location
*
Please Select
Abdomen
Back
Buttock
Chest
Foot
Hand
Heel
Hip
Knee
Lower leg
Sacrum
Shoulder
Thigh
Upper arm
Other
Wound type / cause
*
Please Select
Surgical incision
Traumatic injury
Pressure injury
Diabetic ulcer
Venous ulcer
Arterial ulcer
Burn
Dehisced wound
Skin graft or flap site
Infected wound
Other
Wound size and drainage
*
Rows
Length (cm)
Width (cm)
Depth (cm)
Drainage amount
Drainage characteristics
Current wound assessment
Wound onset / duration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signs relevant to NPWT suitability
Granulation tissue present
Exudate manageable with dressing changes
Periwound skin intact
Wound edges approximable
Undermining or tunneling present
Necrotic tissue present
Active bleeding
Untreated infection
Exposed bone, tendon, or organ
Foul odor
Edema present
Pain with dressing changes
Therapy Plan and Clinical Authorization
Intended NPWT Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Clinician or Facility Name
*
First Name
Middle Name
Last Name
Submit Form
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