Corstrata Virtual Wound Care Services

Virtual Wound Care Services
Corstrata Nursing Services, PC
- At this time, Corstrata offers 2 types of wound care services:
  1. Wound Image Consult/Asynchronous
  2. Live Video Consult/Synchronous
- Wound Image Consult/Asynchronous are offered in all states.
- Live Video Consult/Synchronous are offered in the following States (more states coming soon):
AR, AZ, CA, CO, FL, GA, ID, IL, KY, LA, MA, MO, MS, NC, NJ,

NM, NV, NY, OH, OR, PA, RI, SC, TN, TX, VA, WA, WI

Note - Corstrata services are private pay, out-of-pocket expenses, and are eligible for reimbursement with a FSA, HSA, and HRA.
Your Name*

First NameLast Name
I am requesting services for*

SelfMinorAnother Adult
If for minor or another adult, please provide their name

First NameLast Name
Patient's Home Address/Location of services rendered:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
Phone Number*
Preferred Method of Contact*

EmailPhone Call
Medical Emergency Contact Information

For Emergency Purposes
In the event of a medical emergency during my virtual ostomy visit, I, the patient and/or the authorized signer for the patient,*

give consent for Corstrata to call my medical emergency contact and release my Protected Health Information to ensure proper medical care is provided.do NOT give consent for Corstrata to contact the Medical Emergency Contact listed below.
Emergency Contact Name

First NameLast Name
Phone Number
Relationship to Patient
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMale
Please list any allergies:*
Medical History/Comorbidities: Possible comorbidities and factors that may contribute to delayed healing in this patient include but are not limited to:*

NoneAutoimmune DiseaseCardiac DiseaseESRDPeripheral Arterial DiseaseVenous DiseaseDiabetesMalignancyMalnutritionNeuropathySpinal Cord InjuryStrokeObesityUrinary IncontinenceFecal IncontinenceRespiratory InsufficiencyOther
Take Photo #1
Take Photo #2
Take Photo #3
Take Photo #4
Please Upload your Wound Photo(s), if already taken:

Cancelof
What type of wound do you have?*

ArterialBurnDiabetic Foot UlcerLong standing/chronic woundPressure InjurySurgical IncisionTraumatic Injury (laceration, puncture wound, etc.)VenousOther
Have you noticed any fever, chills, increase in redness, swelling, drainage, or pain around the wound or incision within the past 24 hours?*

YesNo
How often are you changing your dressing?*

At least once a dayEvery 2 to 3 daysAt least once a weekOther
Have you noticed a bad odor coming from your wound?*

YesNo
How did you hear about Corstrata's ostomy support services?*

Social media - i.e.Twitter, Instagram, Facebook, LinkedInFriend or family memberReferring providerProduct manufacturer or supplierOther
Referring Provider Information & Authorization Release
List your Referring Provider's Name

First NameLast Name
Office Phone #
Email
Authorization for Release of Protected Health Information

I, the patient and/or the authorized signer for the patient, acknowledge and hereby authorize the release of my Protected Health Information, to the above listed referring provider. I may revoke this authorization at any time in writing to Corstrata, Inc. at P.O. Box 30643, Savannah, GA 31410 or via email at Support@Corstrata.com. If I do revoke this authorization, it will not have effect on any actions taken prior to receiving the revocation. Unless otherwise revoked, this authorization will expire in 90 days from the date of signature below.
By signing your signature below, you are confirming that you have read and understand the above authorization and/or consent, and agree to the terms and conditions of Corstrata's Virtual Ostomy Support Services.*

Clear
If authorized signer, please list full name and relationship to patient:
Date*

MonthDayYear
Thank you for enrolling with Corstrata Wound Care Services

Please enter your payment information and click submit.

You will then be able to schedule your Virtual Wound Visit on the next page!

Consult Services

Wound Care Consult

$100.00

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Virtual Wound Care Services

Medical Emergency Contact Information

Patient Information

Referring Provider Information & Authorization Release