Use x for Extension. Ex: 999-999-9999 x9999

REASON FOR REFERRAL(Check Services Required) *

Wound Care/Negative Pressure Wound Therapy

Was the patient in an inpatient facility within the last 14 days? *

No          Yes

In my opinion it is medically contradicted for this patient to leave the home because the patient has:

Suspected or confirmed diagnosis of COVID-19
Patient has a condition that may make the patient more susceptible to contracting COVID-19

Authorization to use telehealth:

I authorize the use of telehealth and telecommunications as necessary and appropriate for this patient’s treatment


Who should we contact in case we have additional questions about this referral?

Use x for Extension. Ex: 999-999-9999 x9999

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