Wound Care Patient Referral Submission

Mobile Wound Care Referral & Patient Intake Form

This form is used by home health agencies, physicians, hospitals, or care coordinators to refer patients for mobile wound care evaluation and treatment services. True Medical Advanced Care provides advanced wound care services, including evaluation, debridement, biologic therapies, and chronic wound management directly at the patient’s home or facility.
Section 1 — Referring Agency / Facility Information
Referring Agency / Facility Name
Referring Contact Name
Title/ Role
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
PhoneEmailFax
Section 2 — Patient Information
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Private ResidentsAssisted LivingSkilled Nursing FacilityGroup HomeOther
Facility Name
Section 3 — Insurance Information
MedicareMedicare AdvantageMedicaidCommercial InsuranceSelf Pay
Insurance Provider
Member ID
Group Number
Insurance Card

Cancelof
Secondary Insurance
Member ID
Group Number
Secondary Insurance Card

Cancelof
Section 4 — Wound Information
Diabetic Foot UlcerPressure UlcerVenous UlcerArterial UlcerSurgical WoundTraumatic WoundNon-Healing Chronic WoundOther
FootHeelLegSacrumHipArmOther
Stage 1Stage 2Stage 3Stage 4Unkown
Approximate Wound Size (Length, Width, Depth)
Less Than 4 Weeks1 - 3 Months3 - 6 MonthsOver 6 MonthsUnknown
YesNoUnknown
Section 5 — Current Care
YesNo
Home Health Agency Name
Home Health Nurse Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Standard DressingsDebridementNegative Pressure Therapy WoundHyperbaric OxygenOther
Section 6 — Relevant Medical Conditions
DiabetesPeripheral Artery DiseaseVenous InsufficiencyNeuropathyOsteomyelitisChronic Kidney DiseaseHeart DiseaseSmoking HistoryImmunocompromisedOther
Section 7 — Visit Priority
Urgent (48-72 Hours)Same Day
Clinical Document Upload

Cancelof
Upload Documents (if available):

Please upload any of the following:

Patient Face Sheet
Medication List
Wound Care Notes
Recent Provider Notes
Hospital Discharge Summary
Imaging Reports (if related to wound)
Vascular Studies
Lab Results
Wound Measurements
Prior Wound Photos
Should be Empty:

Mobile Wound Care Referral & Patient Intake Form

Section 1 — Referring Agency / Facility Information

Section 2 — Patient Information

Section 3 — Insurance Information

Section 4 — Wound Information

Section 5 — Current Care

Section 6 — Relevant Medical Conditions

Section 7 — Visit Priority