Request for Activa British Standard hosiery on FP10/GP10

1 Patient name Date Doctor/Clinician Pharmacist Request for Activa British Standard hosiery on FP10/GP10 Activa British Standard hosiery - Patient Record For patients without oedema This is not a made to measure formClinic or Pharmacy Address: (Please specify the address where the patient will collect their hosiery )Patient measurementsHipLeft legRight legA: 5cm below groinB: Widest part of the calfC: Just above the malleolus (ankle bone)D: From back of heel to the longest toePlease noteIf your patient has a long foot in proportion to their other leg measurements, an open-toe option is advisable. Open toe is also appropriate where you require access to the toes. If your patient s measurements do not fit into the stock sizes then a made to measure garment may be more appropriate.

2 If oedema is present in the patient s limb, you may choose to consider applying ActiLymph European Compression hosiery . For more information please see our website at or call customer care on 08450 606 707Is the ActiGlide hosiery Applicator required?(PIP Code: 284-5196) Yes No Garment prescribedFor guidance on which level of compression is most suitable for the patient s condition, please refer to the indications overleaf. Sizing charts vary from one manufacturer to another. Please ensure you prescribe products using the correct chart. Size requested Please state the number of packs you require RedBlueGreenYellowPurpleSizeSmallMediumL argeExtra largeExtra Extra large*HipUp to 107cm107 112cm112 122cm122 132 measuring guideA size indicator can be found by a coloured thread in the stocking * For availability of XXL garments, please see PIP codes on tick a box to indicate garment requiredColour10mmHg14-17mmHgClass 118-24mmHgClass 2 25-35mmHgClass 3 40mmHgCompression Liner (Closed Toe) WhiteSandBlackCompression Liner (Open Toe)SandBelow Knee Stockings (Closed Toe)

3 SandHoneyBlackBelow Knee Stockings (Open Toe)SandThigh Length Stockings (Closed Toe)SandHoneyBlackThigh Length Stockings (Open Toe)SandUnisex SockBlackBrownUnisex Patterned SockBlackTights (Tights are not available on prescription)BlackNaturalAnklet (See website for sizing chart)SandKneecap (See website for sizing chart)SandLeg Ulcer hosiery Kit(1 x below knee open toe stocking plus 2 compression liners)Sand Stocking/White LinersBlack Stocking/White Liners Search under Activa Leg Ulcer hosiery Kit to find Activa Compression Liners on your ordering & Style Colour of size indicator thread in stocking ColourSmallRedMediumBlueLargeGreenExtra LargeYellowExtra Extra LargePurpleLiner Pack - 10mmHg The Activa liner provides light compression for maintenance therapy, palliative care and for patients who are non-concordant with higher levels of compression, working on the assumption that some compression is better than none.

4 They may be used with other compression stockings to increase compression on the limb, or to build the compression level in layers if the patient struggles to apply a higher class of Liner (3 Singles) White 311-8767311-8775311-8783311-8791311-8809 Stocking Liner (3 Singles) Sand 326-9750326-9768326-9776326-9784326-9792 Stocking Liner (3 Singles) Black 387-0805387-0813387-0821387-0839387-0847 Stocking Liner Open Toe (3 Singles) Sand 340-3557340-3565340-3573340-3581340-3599 Class 1 - 14-17mmHgActiva Class I, medically proven, graduated support hosiery provides effective compression in the treatment of superficial and early varicose veins, including those during pregnancy. Class 1 hosiery can reduce the risk of Deep Vein Thrombosis in lower risk groups during long-distance travel or in long periods of Length Sand259-0305259-0339259-0362259-0396-Thi gh Length Honey259-0313259-0347259-0370259-0404-Th igh Length Black259-0321259-0354259-0388259-0412-Be low Knee Sand259-0420259-0446259-0461259-0487-Bel ow Knee Honey259-0438259-0453259-0479259-0495-Be low Knee Black278-2373278-2381278-2399278-2407-Be low Knee Open ToeSand268-1500268-1518268-1526268-15343 17-2723 Unisex SockBlack278-2415278-2423278-2431278-244 9-Unisex Patterned SockBlack 356-9993357-0009357-0017357-0025-TightsB lack286-9998287-0004287-0012287-0020-Cla ss 2 - 18-24mmHgActiva Class 2, medically approved.

5 Graduated support hosiery provides compression for medium severity varicose veins or prevention of venous leg ulcers. Class 2 hosiery can reduce the risk of Deep Vein Thrombosis in higher risk groups during long distance travel. Thigh Length Sand259-0503259-0537259-0560259-0594-Thi gh Length Honey259-0511259-0545259-0578259-0602-Th igh Length Black259-0529259-0552259-0586259-0610-Th igh Length Open ToeSand259-0859259-0867259-0875259-0883- Below Knee Sand259-0628259-0685259-0743259-0784-Bel ow Knee Honey259-0651259-0701259-0750259-0792-Be low Knee Black259-0669259-0735259-0776259-0800-Be low Knee Open ToeSand259-0818259-0826259-0834259-08423 17-2707 Unisex SockBlack259-4463259-0891259-0917259-093 3-Unisex SockBrown259-4471259-0909259-0925259-094 1-Unisex Patterned SockBlack357-0033357-0041357-0058357-006 6-Anklets Sand259-0958259-0966259-0974259-0982-Kne ecapsSand259-1204259-1212259-1220259-123 8-TightsNatural287-0038287-0046287-00532 87-0061-Class 3 - 25-35mmHg Activa

6 Class 3 hosiery provides effective management of chronic venous insufficiency and eases away the pain and discomfort of severe varicose veins and chronic leg ulcers. The hosiery can also be used in the prevention of leg ulcer Length Open ToeSand259-1287259-1295259-1303259-1311- Below Knee Open ToeSand259-1246259-1253259-1261259-12793 10-297740mmHg Leg Ulcer hosiery KitThe Activa Leg Ulcer hosiery Kit is designed to be an alternative treatment and maintenance solution in the management of uncomplicated venous leg disorders. The hosiery kit is suitable for patients who will not accept compression bandages and is particularly suitable for self-caring and younger (1 Sand Class 3 Stocking + 2 White Liners)-311-9021311-9047311-9054311-9070 311-9088 Black (1 Black Class 3 Stocking + 2 Sand Liners)-366-5593366-5601366-5619366-5627 366-5635 ActiGlide hosiery Applicator ActiGlide hosiery ApplicatorOne Size Fits All 284-5196 For further information please call 08450 606 707 to speak directly with a Customer Care Advisor or visit our website Activa British Standard hosiery RangeActiva , ActiLymph and ActiGlide are registered to L&R Medical UK Ltd, formerly known as Activa Healthcare Ltd M002