Wound Care Referral Form

First Name *

Last Name *

Cell Phone *

City

Zip code *

State

Are you currently getting treated for this wound?

How long have you had the wound?

What Type of Wound

What medical insurance do you have? *

By submiting this form, you acknowledge and agree that you are voluntarily providing personal and health information to Dinkum Prospect Healthcare for the purpose of scheduling, care coordination, or responding to your inquiry. We are committed to protecting your privacy in accordance with HIPAA regulations. The information you provide will be used and disclosed only as necessary for your care and as permitted or required by law.

Please do not submit confidential or sensitive information unrelated to your care through this form. If you have a medical emergency, please call 911 or go to the nearest emergency room.