Provider Referral Form

How to Refer a Patient  

Referring is simple. Please provide the following information so our team can contact the patient within 24–48 hours:

• Patient demographics

• Insurance information

• Recent clinical notes

• Wound history and current regimen

• Referring provider contact information

You may submit referrals by phone, email, or through this form.

Intake & Scheduling: 773‑671‑8188

Clinical Line: 773‑671‑8199

Email (Intake): intake@woundsciencespecialists.com

Email (Clinical): doc@woundsciencespecialists.com