Referral to Wound Care
Fax Number: (405) 694-4547 Email: intake@dynamic-woundcare.com
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Check if patient is currently in the hospital:
Hospital
Referring Facility:
Referring Physician:
Wound Information or dx Code:
Onset Date:
-
Month
-
Day
Year
Date
Wound Location(s):
Wound Description:
Needed Items: (if available):
Face Sheet
Medical Problem List
Medication List
Diagnostic Studies
Recent Labs Including HGBA1C if Diabetic
Vascular Studies, ABI if Available
If recently hospitalized: Discharge Summary
Other
Submit
Should be Empty: