All Forms·Corona · InlandDME@gmail.com
Inland DME

Wound Care Order Form

1426 W. 6th St Suite 108 Corona, CA 92882 · (951) 278-1222

Patient Information

Wound Care Supplies

Select all that apply. Quantities are prefilled and may be edited.

Wound Fillers & Collagen

A6010Collagen Powder Wound Filler
A6021Collagen Matrix Dressing - 16 sq in or less
A6022Collagen Matrix Dressing - more than 16 to 48 sq in

Alginate & Gelling Fiber

A6196Alginate / Gelling Fiber Dressing - 16 sq in or less
A6197Alginate / Gelling Fiber Dressing - more than 16 to 48 sq in

Bordered Foam Dressings

A6212Bordered Foam Dressing - 16 sq in or less
A6213Bordered Foam Dressing - more than 16 to 48 sq in

Plain & Bordered Gauze

A6402Sterile Gauze Pad - 16 sq in or less
A6216Non-Sterile Gauze Pad - 16 sq in or less
A6219Sterile Bordered Gauze - 16 sq in or less
A6220Sterile Bordered Gauze - more than 16 to 48 sq in

Impregnated Gauze & Packing

A6222Impregnated Gauze - 16 sq in or less
A6223Impregnated Gauze - more than 16 to 48 sq in
A6224Impregnated Gauze - more than 48 sq in
A6266Impregnated Packing Strip / Rolled Gauze - per yard

Specialty Absorptive Dressings

A6252Specialty Absorptive Dressing, No Border - more than 16 to 48 sq in
A6254Specialty Absorptive Dressing with Border - 16 sq in or less

Bandages & Wraps

A6446Sterile Conforming Gauze Bandage - 3 to under 5 in wide
A6454Self-Adherent Cohesive Bandage - 3 to under 5 in wide
A6455Self-Adherent Cohesive Bandage - 5 in or wider

Skin Protection & Irrigation

A6250Skin Barrier Cream / Ointment
A4217Sterile Water or Saline

Prescriber Information

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