Refer a patient

Send a referral by secure fax, secure email, or online. We accept partial information and follow up for the rest. We contact the patient the same business day and bill Medicare Part B directly. Visit notes and progress photos come back to your EMR.

Please note: for all new referrals, please send them to referrals@victorywoundcare.com, or to our fax number at 469-312-2506.

Secure fax

469-312-2506

Referrals email

referrals@victorywoundcare.com

Online form

Request a Visit →

Printable referral form

Referring provider

Date

Referring provider / NP / RN

Practice or facility

NPI

Phone

Fax

Patient

Patient name

Date of birth

Phone

Primary insurance / Medicare ID

Address where care is provided (home, independent living, or assisted living)

Wound

Wound type

Location

Approx. duration

Treatments tried

Relevant history / notes

Ordering provider (if applicable)

Ordering provider name

NPI

Signature

Date

Care is delivered by Advanced Practice Providers within their scope of practice, with physician oversight, and provided only when medically necessary. Patients may be referred by a primary care provider, specialist, home health agency, or facility, or may contact us directly. Fax completed forms to 469-312-2506. Please send PHI by secure fax or secure email only.