Woundlocal B2C Patient Referral Form

Does the patient live in Texas?* This field is required.At the moment, we are servicing only Texas residents.

Yes

Is the patient suffering from a non healing wound?* This field is required.A non-healing wound, often called a chronic wound, is a type of wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do. Examples of these wounds include: 1. Pressure Ulcers (Bedsores): These occur in individuals who are bedridden or immobile for extended periods. Constant pressure on certain body areas, especially over bony prominences, leads to these wounds. 2. Diabetic Ulcers: Common in people with diabetes, these ulcers typically occur on the feet and result from poor circulation, nerve damage, and difficulty fighting infection.

Yes

What type of wound does the patient have?* This field is required.

Pressure Ulcer

Diabetic Ulcer

Venous Ulcer

Arterial Ulcer

Vasculitic Ulcer

Infected Surgical Wound

Traumatic Wound

Radiation Burn

I Don't Know

Other

Has the patient's wound been treated for 30 days?* This field is required.Including any type of treatment, such as home treatment, clinics/doctors, nurses, and so on.

Yes

What kind of treatment has the patient received thus far?* This field is required.Please be as descriptive as possible

Who is the patient's insurer?* This field is required.

Medicare

Tricare

BCBS Medicare

BCBS PPO

Humana

UHC Medicare

UHC PPO

Cigna

Wellmed

Superior MMP

Molina MMP

UMR

Health Texas

Wellcare

Aetna

Other

Patient's Date of Birth* This field is required.

Date

What is the patient's name?* This field is required.

First Name

Last Name

What is the referrer's name?Leave blank if the patient is self-referring themselves

First Name

Last Name

What is your cell number?* This field is required.This will be our primary means of communication

Area Code

Phone Number

What is your email? * This field is required.We will use this email to contact you

example@example.com

Anything else in particular that you wish to share with us?If not, leave empty

Woundlocal B2C Patient Referral Form