-Consent to Receive Wound Care Treatment-

Consent for Wound Care Treatment
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How did you hear about PNW Wound Specialist?
Do you currently have an established Primary Care Provider
PCP / Primary Care Provider Name
Clinic or Practice Name
PCP Phone Number
Date Last Seen by PCP
A current PCP is strongly recommended because many insurance plans require PCP involvement in care coordination. Our team may discuss next steps with you before your first visit.
Section 1 - Patient Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
ACCESS TO PATIENT PORTAL
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Race
Ethnicity
Veteran
Marital Status
Primary Language
Sex
Sexual Orientation
Gender Identity
Facility Name (if applicable)
Relationship to Patient
Representative date of birth (optional; if someone is signing for the patient)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patients Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Information
Full Name
Relationship to Patient
Phone Number
Address
Home Health involved in your care?
Organization
Start Date (approx.)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred Pharmacy

To help us provide timely care, please tell us where you would like any prescriptions sent if medication is prescribed during your treatment.
Preferred Pharmacy Name:
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (optional) :
Please enter a valid phone number.Format: (000) 000-0000.
Is this your preferred pharmacy for all prescriptions?
please explain:
Prescription Authorization:
Section 2 – Consent Statement
Consent for routine wound care

I consent to evaluation and routine wound care by PNW Wound Specialist, LLC. This may include reviewing my history, examining and measuring wounds, cleansing, dressing changes, education, and collecting a wound specimen when recommended and explained by my treating clinician.

Before a specific procedure, my treating clinician will explain its purpose, expected benefits, important risks, reasonable alternatives, and what may happen without treatment. Debridement, advanced therapies, and other procedures require the appropriate treatment-specific discussion and consent. This form does not authorize every future procedure.

I may ask questions, request language or communication assistance, take time to decide, and refuse or stop a treatment. No healing or other outcome is guaranteed. Refusing a particular treatment does not waive my other rights or my right to discuss alternatives.

A specimen may be sent to an outside laboratory that bills separately. Any patient responsibility must comply with applicable law, my coverage, and payer rules; this consent is not a blanket agreement to pay denied or prohibited charges.

My signature confirms that I understand this routine-care consent and have had the opportunity to ask questions. If a representative signs, the care team must verify the patient’s decision-making ability and the representative’s legal authority; a family relationship alone does not establish authority.

This form is not monitored for emergencies. Call 911 for immediate danger or a medical emergency.
Patient or Authorized Representative Signature

A representative may sign only when legally authorized. Staff will verify that authority.
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Consent for Wound Care Treatment

Section 1 - Patient Information

Emergency Contact Information

Preferred Pharmacy

Section 2 – Consent Statement

Consent for routine wound care