Application Form
Equine Wound Center Endorsement Procedure
Part 1
Clinic Contact Details
Clinic Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Named Contact Person(s)
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Part 2 Acute Wounds
Wound patients over past 3 years, please fill in numbers:
Ambulatory Patients
Sutured; standing:
Sutured; recumbent:
Results; primary healing:
Results; partial/total dehiscence:
Not sutured:
Hospitalised Patients
Sutured; standing:
Sutured; recumbent:
Casted:
Bandaged:
Results; primary healing:
Results; partial/total dehiscence:
Not sutured:
Optional explanation of abovementioned points
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Part 2 (continued) Second Intention Healing/Chronic Wounds
Wound patients over past 3 years, please fill in numbers:
Ambulatory Patients
Average Size:
Dressings used:
Medications used:
Antibiotics
NSAIDs
Other
Please detail 'other' medications:
Other techniques:
Average number of days before completely healed:
Hospitalised Patients
Average Size:
Dressings used:
Medications used:
Antibiotics
NSAIDs
Other
Please detail 'other':
Other techniques:
Average number of days before completely healed:
Number of days hospitalised:
Surgical Techniques
Reconstructive Surgery
Skin Grafts
Optional explanation of abovementioned points
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Part 3 Clinical Staff Responsible for Wound Treatment
Person 1: DVM
Name
First Name
Last Name
Qualifications
Experience with:
Wound debridement
Suturing complicated wounds
Lavage of synovial structures
Management of complicated wounds
Various wound dressings
Removal osseous sequestrum
Cast application
Cast monitoring
Reconstructive procedures (eg. skin flaps)
Skin grafting
Person 2: DVM
Name
First Name
Last Name
Qualifications
Experience with:
Wound debridement
Suturing complicated wounds
Lavage of synovial structures
Management of complicated wounds
Various wound dressings
Removal osseous sequestrum
Cast application
Cast monitoring
Reconstructive procedures (eg. skin flaps)
Skin grafting
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Part 3 (continued) Clinical Staff Responsible for Wound Treatment
Person 3: Nurse
Name
First Name
Last Name
Qualifications
Experience assisting with:
Wound debridement
Suturing complicated wounds
Lavage of synovial structures
Management of complicated wounds
Various wound dressings
Removal osseous sequestrum
Cast application
Cast monitoring
Reconstructive procedures (eg. skin flaps)
Skin grafting
Person 4: Nurse
Name
First Name
Last Name
Qualifications
Experience assisting with:
Wound debridement
Suturing complicated wounds
Lavage of synovial structures
Management of complicated wounds
Various wound dressings
Removal osseous sequestrum
Cast application
Cast monitoring
Reconstructive procedures (eg. skin flaps)
Skin grafting
Optional explanation of abovementioned points:
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Part 4 Physical Facilities and Equipment
Surgery Facilities
Surgery room
Operating table
Inhalational anaesthesia
Other anaesthesia
Recovery box
Assisted recovery
Equipment
Radiography
Ultrasound
Dermatome
Hand knife
Meek equipment
Mesh graft equipment
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Part 5 Research and Education
Is the clinic/future wound centre willing to:
(If unsure now but may be able to in the future please explain in the box below)
Train Colleagues
Yes
No
Unsure
Maintain competence
Yes
No
Unsure
Regularly update knowledge
Yes
No
Unsure
Attend EWC meetings twice yearly (annual VWHA Spring & online EWC Autumn meeting)
Yes, both
Annual VWHA Spring Meeting
Online EWC Autumn Meeting
Unsure
Share and discuss cases
Yes
No
Unsure
Collaborate in general
Yes
No
Unsure
Collect data of wound patients
Yes
No
Unsure
Collaborate in clinical research
Yes
No
Unsure
Optional explanation of abovementioned points
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Should be Empty: