New Patient Referral Form - United Wound Healing 2026

1. Click ‘Get Form’ to open the New Patient Referral Form in the editor.
2. Begin by filling out the 'Facility Name', 'Your Name', and 'Contact Number' fields. Ensure all information is accurate for seamless communication.
3. Next, enter the 'Patient Name' and 'Date of Birth'. This information is crucial for patient identification and records.
4. Complete the 'MD Order for Wound Care Referral' section, ensuring it is signed and dated appropriately.
5. In the 'GENERAL PATIENT INFORMATION' section, indicate if the patient is in hospice or a re-admission. Also, provide the date of the last influenza vaccination.
6. For each wound location, fill in details such as 'Wound Location', 'Date Acquired', 'Type of Wound', and 'Stage'. Make sure to check if it was facility-acquired.
7. If there are additional wounds, note that they should be included on a separate sheet as indicated.
8. Once completed, scan and email the form along with required documents to your respective state’s email address provided at the top of the form.

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