New Patient Referral

New Patient Referral Form

Finding a wound care clinic that you can trust is important. The Angeles Wound Care Institute is proud to provide Bend and surrounding areas with Advanced Wound Care Technology and state-of-the-art treatment for faster healing.
Please complete this form to the best of your ability, and click submit. Our Patient Care Coordinator will reach out to your patient to schedule a consultation within one business day.

Referrer Information:

*Date

*Referring Facility / Physician Name

*Referrer Phone Number

Referrer Fax Number

Primary Care Provider (if different than referrer)

Patient Information

Patient Name

*First Name

Middle Name

*Last Name

Suffix

*Patient Date of Birth

Patient Address

*Street Address 1

Street Address 2

*City

*State

*Zip

*Country

*Patient Phone Number

Primary Insurance
We consider medicare primary billing.

ID #

Group #

*Insurance Plan Name

Secondary Insurance

ID #

Group #

Insurance Plan Name

Wound Information:

*Wound Location

*Wound Size: (L x W x D, cm)

*How long has the patient had the wound?

ICD-10 Code(s)

Please attach the patient's most recent medical chart and notes to include medications, medical history, wound info, progress notes, patient insurance, and license info.

Only accept image and pdf file

Other Comments

New Patient Referral

New Patient Referral Form

Why Choose Angeles Wound Care Institute for Your Patients?

Same Day Patient Outreach & Scheduling

25+ Years of Experience

We Take Most Insurance Plans.

Direct Line to Our Patient Care Coordinator

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Certified by the American Board of Plastic Surgery