Plurogel Intake Form

Facility name*
Facility type*
Medline account*
Prescribing clinician name
Prescribing clinician phone
Main contact email*

This email will be used on all future communications including weekly update links.
Has the facility prescribing clinician approved this trial?
Additional Info required

Please add Name, phone number and email of the individual who writes orders for wound treatment below:
Full Name
Phone
Email
Has the person responsible for writing wound orders approved this trial?
Request Denied
In order to set up a proper trial we need approval from the Medical Facility Director.

Patient Information
Please input patient information
Patient 1
Age
Gender
- Male
- Female
Etiology of wound*
Location of wound*
Size of wound*
Duration of wound*
Percent of non-viable tissue*
Epibole present?*
Is the wound stable eschar on the HEEL ?
Does the patient have gangrene or avascular tissue ?
Is thick eschar present?
Thick Eschar can take longer to see progress. Expect 2 weeks to see progress.
Current treatment plan*
Previous attempted treatments*
Photos of wound - Patient 1
Drop files here or

Accepted file types: jpg, gif, png.
Patient 2
Age
Gender
- Male
- Female
Etiology of wound*
Location of wound*
Size of wound*
Duration of wound*
Percent of non-viable tissue*
Epibole present?*
Is the wound stable eschar on the HEEL ?
Does the patient have gangrene or avascular tissue ?
Is thick eschar present?
Current treatment plan*
Previous attempted treatments*
Photos of wound - Patient 2
Drop files here or

Accepted file types: jpg, gif, png.
Patient 3
Age
Gender
- Male
- Female
Etiology of wound*
Location of wound*
Size of wound*
Duration of wound*
Percent of non-viable tissue*
Epibole present?*
Is the wound stable eschar on the HEEL ?
Does the patient have gangrene or avascular tissue ?
Is thick eschar present?
Current treatment plan*
Previous attempted treatments*
Photos of wound - Patient 3
Drop files here or

Accepted file types: jpg, gif, png.
Request Denied

Your patient meets one or more of the following criteria excluding them form the evaluation trial.

Exclusions:
1.) Is Epibole present? YES
2.) Is the wound stable eschar on the HEEL ? YES
3) Does the patient have gangrene or avascular tissue ? YES

We suggest using a different patient for this trial.
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Plurogel Intake Form

Additional Info required

Request Denied

Patient Information

Patient 1

Patient 2

Patient 3

Request Denied