If this follow-up is for a report sent by Royal Mail post, please enter the patient reference number shown on the green card.

If the original extravasation report was sent via the green card online system, please enter the electronic reference number supplied to you at that time.

REFERENCE NUMBER
Please give details of any chronic pharmacological treatment
If the extravasation injury ulcerated, was there any functional loss in the affected limb?	Yes No
If yes, please give details -
If surgery was performed, please give brief details

OUTCOME

Resolved following acute treatment
Resolved using pharmacological treatment only
Extravasation ulcerated and required skin grafting
Patient lost to follow up