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Wound Care
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Health Professionals
Wound Care Form
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Wound Care Form
Fields marked with an asterisk(*) are required.
Patient Name
Date of Birth
Evaluation and Treatment with outpatient Wound Healing Center for wound management and dressing changes.
Location of Wound
Wound VAC Management
Location of Wound
Type of Sponge
Pressure Setting
Frequency of Change
Patient Diagnosis
Diabetic Foot Ulcer
Left
Right
Chronic venous hypertension with ulcer of lower extremity
Left
Right
Post-surgical wound of
Arterial wound of
Wound secondary to burn
Wound secondary to trauma Location:
Pressure ulcer (no sacral decubitus) Location:
Unspecified Wound/ Other
Hyperbaric Oxygen Therapy (HBO)
Later effects of radiation
Yes
No
Osteoradionecrosis of
Other Reason
Name of Exam to be Performed (CPT CODE):
General Outpatient Evaluation and Management - CPT 99215
Yes
No
Other Reason (Fill in the blank)
Referring Provider Name
Provider NPI
Provider Tax ID#
Date of Order
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