New Patient Referral

New Patient Referral Form:
PLEASE NOTE: Completed form must be received 72 hours prior to Wound Rounds to ensure patient registration and insurance authroization occurs.

*Please contact us if you would like to learn more about our PointClickCare and MatrixCare integrations to avoid future paperwork.
Facility Name*
What State is your Facility In?*
Your Name*

First NameLast Name
Contact Number*
E-mail*
Resident's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
General Patient Information
Is the Resident on Hospice?*

YesNo
Re-admission to United Wound Healing*

YesNoUnsure
How Many Wounds or Skin Condition Does this Resident Have?*

Wound #
Wound 1

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound was Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Was the wound present on admission to the SNF?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 2

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 3

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 4

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 5

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 6

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 7

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Wound #
Wound 8

The following must be completed for each wound location
Wound Location*
(e.g. sacrum, heel, etc.)
Side*
Date Wound Acquired*

MonthDayYear
(if unknown select resident’s admission date to facility)
Facility Acquired?*
Type of Wound*
Stage*
Take Picture of Your Wound (optional)

Please upload the following files:
Most recent patient face sheet*

Browse Files

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Physician order for wound care evaluation and treatment*

Browse Files

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History and physical exam, discharge summary, and/or problem list strongly encouraged

Browse Files

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Questions? If you have questions, please call us at 1-855-255-1750

Did you know we now have a direct interface with your EMR? Contact us to learn more about reducing paperwork and receiving our notes directly.
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New Patient Referral Form: