Referral Form: Complex Wound Healing Clinic
Please complete this referral form (*Information required)
Date: *
Name:
Sex:
Age:
Address:
Date of Birth:
Home Phone #:
MRN
Mobile Phone #:*
Wound Location:
Wound Start Day:
Reason/Goal for Referral:
Is patient receiving Wound Care from District Nurse? Yes No
If Yes,
DN Start Day:
Known Allergy:
Wound Etiology (please  one):
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Pressure Ulcer
Diabetic/Neuropathic Foot Ulcer
Lower Leg Ulcer (venous/arterial/Mixed)
Trauma
Post - Surgical
Burn/Scald
Infectious
Inflammatory
Unknown
Other *
Comorbidities/Wound Healing Impeding Factors (please  all that applies):
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Pressure
Diabetes/Neuropathy
Venous Stasis
Peripheral Edema
Arterial Insufficiency
Nutrition
Obesity
Tobacco Use
Immobility
Immunosuppression
Prednisone/Steroid Use >20mg/day)
Infection
Inflammation
Foreign Body
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Granuloma
Patient Adherence
Other *
Current Dressing Protocol:
Dressing Products Previously Used:*
Is patient able to transfer independently? Yes No (***Patient must be able to transfer
independently or with the assistance of accompanied family/caregiver)
Language spoken:
Interpreter required? Yes No
Please attach any pertinent recent lab work, pathology reports, medical imaging reports, etc.*
Referee Name:
Title:*
Unit:*
Phone Number:
e-mail address:
Complex Wound Clinic Referral Form
Providing person-centered education to promote healthy life-style change, and ability to selfmanagement
Inclusion Criteria
Patients of age 19 and over
Patient of age under 19 in collaboration with Child and Youth Services
Patients with lower leg/foot ulcers with ABI >0.5(if ABI<0.5, refer to vascular surgeon first)
Even with standard wound care (Sheehan 2013, Coerper et al 2009):
a) Patients with acute wounds that fail to heal in 6 week
b) Patients with chronic wounds that fail to heal in 12 weeks
c) Patients with chronic wounds that fail to have 30% size reduction (length x width) after 4
weeks of standard wound care
Patient can transfer independently or assisted by accompanied caregiver
Patient is committed to:
a) Adherence to clinic visits
b) Adherence to treatment plan
c) Tobacco reduction/cessation
d) Optimal nutrition, including protein, calorie, fluid
e) Optimal Diabetic control with A1C < 9
Exclusion Criteria:
Patients’ wounds have not been managed with standard wound care
Home bound patients who cannot attend the clinic visit
Patients who require mechanical lift for transfer
Patients with lower leg/foot ulcers with ABI <0.5, and are not a candidate for revascularization
Patients cannot commit to the wound treatment plan, clinic visits, healthy life style modifications,
tobacco reduction/cessation, optimal nutrition intake, Diabetic control, etc.
Exception may be considered for individual client/patient in collaboration with Home Health WCCs
and/or Medical Professionals managing complex acute or chronic wounds (e.g. ID Specialists,
Surgeons). Please contact the Complex Wound Clinic CNS directly via e-mail (