Healing Hands Wound Clinic

1900 Matlock Rd, Ste 304 Mansfield TX, 76063

T:(817) 380-3201 | F:(817) 886-9006

Schedule an Appointment

Refer Your Patient Here

*Saturday Appointments Available!

For Providers:

If you are a physician or a physician’s office, please send us a fax with the following information to (817) 886-9006:

• Physician’s name and office phone number
• Office Address
• Patient’s Name
• Patient Demographic
• Reason for referral
• Patient’s Insurance information
• Any relevant labs/progress notes for this visit

OR

Complete the following referral form:

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Patient's Name *

First

Last

Patient's Phone Number: *

Date of Birth: *

Wound Location/ Number of Wounds:

Reason for Consult: *

• Diabetic Foot Ulcer
• Venous Ulcer
• Arterial Ulcer
• Pressure Ulcer
• Non-Healing Surgical Wound
• Wound Vac
• Other

Consult Wound Care: Patient will be assessed by Wound Care provider followed by any recommended treatment.

If other, please explain or add any other notes for the wound specialist below:

Physician's Name *

First

Last

Physician's Office/ Direct Number: *

Office Fax Number:

Today's Date:

Will you please fax over patient demographics, any relevant labs and H&P with referral form to (817) 886-9006? *

NOTE: All Medicaid and/or HMO plans will require prior authorization and referral for patient visit.

Submit

Thank you for your kind referral!