Express Referral Form HackensackMeridianHealth.org/Wound Please return completed form via fax. Hackensack University Medical Center (See back side for locations University Medical Center and fax numbers) JFK Medical Center Pascack Valley Medical Center Mountainside Medical Center Raritan Bay Medical Center Southern Ocean Medical Center Patient Information

Name: ______DOB: ______Phone: ______

Patient’s Address: Home or Facility? ______

Primary Insurance: ______ID# ______

Secondary Insurance: ______ID# ______

Where is the non-healing wound? ______

How long has the patient had this non-healing wound? ______

Ambulatory status of patient: ______Can patient complete paperwork? Yes No

Referring Physician Name: ______

Address: ______Phone: ______

Primary Care Physician Name: ______

Address: ______Phone: ______

Diagnosis or condition patient is referred for:

■ Acute peripheral arterial insufficiency ■ Cellulitis ■ Compromised or failed flap or graft ■ Arterial ulcer ■ Diabetic ulcer (any) ■ Hemorrhagic cystitis ■ Decubitus ulcer ■ Osteoradionecrosis ■ Osteomyelitis ■ Insect bite ■ Post-operative wound ■ Pressure ulcer ■ Peripheral vascular disease ■ Soft-tissue necrosis ■ Thermal burn ■ Radiation proctitis ■ Venous ulcer ■ Chronic refractory osteomyelitis ■ Trauma ■ Actinomycosis ■ Other ■ Acute traumatic peripheral ischemia ■ Wound dehiscense

Referral Information ■ Evaluation and treatment: Both specialized wound care and hyperbaric medicine ■ Evaluation and treatment: Specialized wound care only ■ Evaluation and treatment: Hyperbaric medicine only HackensackMeridianHealth.org/Wound

Hackensack Meridian Health’s Centers for Wound Healing blend experience and expertise with the latest advancements and technologies to provide a healing touch in wound care and hyperbaric oxygen (HBO) therapy. Personal treatment plans are developed for each patient through Hackensack Meridian Health’s ten convenient locations at Hackensack University Medical Center, Jersey Shore University Medical Center, JFK Medical Center, Bayshore Medical Center, Ocean Medical Center, Palisades Medical Center, Pascack Valley Medical Center, Mountainside Medical Center, Raritan Bay Medical Center and Southern Ocean Medical Center.

Hackensack University Medical Center Palisades Medical Center 20 Prospect Avenue, Suite 410 7600 River Road Hackensack, NJ 07601 North Bergen, NJ 07047 Phone: 551-996-4070 Phone: 201-854-5203 Fax: 551-996-4072 Fax: 201-854-5199

Jersey Shore University Medical Center Pascack Valley Medical Center 1945 Route 33 70 Old Hook Road Neptune, NJ 07753 Westwood, NJ 07675 Phone: 732-776-4430 Phone: 201-781-1530 Fax: 732-776-4272 Fax: 201-781-1531

JFK Medical Center Mountainside Medical Center 65 James Street 1 Bay Avenue Edison, NJ 08820 Montclair, NJ 07042 Phone: 732-321-7022 Phone: 973-429-6988 Fax: 732-767-2963 Fax: 973-680-7779

Bayshore Medical Center Raritan Bay Medical Center 735 North Beers Street 530 New Brunswick Avenue Holmdel, NJ 07733 Perth Amboy, NJ 08861 Phone: 732-497-1611 Phone: 732-324-3152 Fax: 732-497-1702 Fax: 732-324-4836

Ocean Medical Center Southern Ocean Medical Center 425 Jack Martin Boulevard 1140 Route 72 West Brick, NJ 08724 Manahawkin, NJ 08050 Phone: 732-840-3399 Phone: 609-978-3077 Fax: 732-836-4579 Fax: 609-978-4329