Refer a Patient

Welcome to Wound Wellness, where expert wound care is our focus. If you're a healthcare provider or part of a community organization with a patient or individual in need of advanced wound care, we're here to assist. Please fill out the form below to start the referral process.

Our team, committed to excellence in wound treatment, will get back to you within one business day. For immediate referrals or to discuss specific wound care needs, please contact us at (469) 962-3499. We are dedicated to delivering prompt and effective care, ensuring those you refer receive the best possible treatment for their wound care needs.

PATIENT INFORMATION

First Name

Last Name

PATIENT ADDRESS

Address

Address Line 2

City

State

Postal / Zip code

Patient's date of birth required

Patient's Email Address

Patient's Phone number

Additional Phone number

PATIENT INSURANCE

Primary Insurance Provider

Primary Insurance Group ID

Primary Insurance Member ID

Secondary Insurance Provider

Secondary Insurance Group ID

Primary Insurance Card

Upload File

Upload supported file (Max 15MB)

Secondary Insurance Card

Upload File

Upload supported file (Max 15MB)

PRIMARY CARE PHYSICIAN

Primary Care Provider

Primary Care Provider Phone

Primary Care Provider Fax

HELPFUL DOCUMENTATION

Image of Wound (1)

Upload File

Upload supported file (Max 15MB)

Image of Wound (2)

Upload File

Upload supported file (Max 15MB)

Image of Wound (3)

Upload File

Upload supported file (Max 15MB)

History and Physical Documentation

Upload File

Upload supported file (Max 15MB)

Applicable Labs for Previous 3 Months

Upload File

Upload supported file (Max 15MB)

Previous ABI/Vascular/Imaging Documentation

Upload File

Upload supported file (Max 15MB)

Post Surgical Wounds- Orders for US Wound to Evaluate and Treat

Upload File

Upload supported file (Max 15MB)

REFERRAL PARTNER INFORMATION

First Name*

Last Name

Referring Contact Phone

Referring Contact Email

POWER OF ATTORNEY

Does the patient currently make their own medical decisions?

Yes

No

By checking this box, I consent to receive transactional messages via SMS and/or e-mail that are related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others via SMS. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

Refer a Patient

PATIENT INFORMATION

PATIENT ADDRESS

PATIENT INSURANCE

PRIMARY CARE PHYSICIAN

HELPFUL DOCUMENTATION

REFERRAL PARTNER INFORMATION

POWER OF ATTORNEY

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