Contact Form

If you have a hard to heal wound and would like us to contact you with more information, please complete the brief form below.
 

Did You Know?
The average length of treatment for a wound healing patient is 61 days. Thus, if you have intentions of undergoing wound healing treatment, we recommend that you find a wound healing center near where you live, or, that you make short-term furnished housing arrangements close to where you will be obtaining your care.

Required Information*

First Name*

Last Name*

Email Address*

Main Phone*

Main Phone Is*

Home Number  Work Number

Friend or Relative's Number

Optional Information

Address

City

State

Zip


Preferred method to contact you
 


Issue/Problem Of Interest/Concern
(check all that apply)

Diabetic Wound Of the Lower
    Extremity
Compromised Skin Grafts and Flaps
Delayed Radiation Injury
Necrotizing Soft Tissue Infections
Osteomyelitis (Refractory)
Crush Injury
Compartment Syndrome
Acute Traumatic Ischemias
Clostridial Myonecrosis (Gas
    Gangrene)
Carbon Monoxide Poisioning
Decompression Sickness
Air Or Gas Embolism
Other (please explain below)
 

I am (check one)
a potential patient
seeking info for someone else
a physician
an Allied health professional
a Governmental/social services
    rep
a Media rep
Other (please explain below)







 

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