Wound Care Referral

Advanced Wound Care of Central Texas

Referral Form
Date

MonthDayYear
Date
STAT1st Available
Arterial UlcerBurn/Post RadiationDiabetic UlcerInfectious WoundPressure Injury Stage 1Pressure Injury Stage 2Pressure Injury Stage 3Pressure Injury Stage 4Venous Leg UlcerOther
Other Wound:
NewLess than 30 daysMore than 30 daysUnknown
Lower Extremity LeftLower Extremity RightUpper Extremity LeftUpper Extremity RightTrunkOther
Other Location:
MedicareMedicare Part BTricareAetnaBCBSCignaHumanaMolinaUHCOther
Other Insurance:
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Number*
Please enter a valid phone number.Format: (000) 000-0000.
Evening Number
Please enter a valid phone number.Format: (000) 000-0000.
Caretaker Name

First NameLast Name
Caretaker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Reason for Consultation*
Diagnosis
ICD 10 (all that apply)
Please send the following or any relevant information to our

HIPAA-compliant Fax Number: 512-594-7641
- Patient’s demographics/insurance/updated history and physician report
- Lab Reports
- Pictures of Wound (if available)
- Patient’s Last 30-Days Progress Notes
One of our Team members will contact patient to schedule the appointment.
Referring Provider

NameCredentials
Signature
Should be Empty:

Advanced Wound Care of Central Texas