Have you or your loved one been diagnosed with any of the following medical conditions? Check all that apply.
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Diabetic foot ulcers (DFU)
Venous stasis ulcers
Pressure ulcers
Neuropathy-related wounds
Burn-related wounds
Surgical wounds
Surgical wound dehiscence
Traumatic wounds
Are you or your loved one a diabetic?
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Yes
No
How long have you or your loved one had the wound?
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Less than 30 days
Over 30 days
Do you or your loved one have reliable transportation to go to appointments? *
Yes
No
What insurance do you have?
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Medicare
Other
First Name
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Last Name
*
Email
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Phone Number
*
Zip Code
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SUBMIT