Referrals

To refer a patient to the Wound Healing & Hyperbaric Medicine Center at Hartford Hospital, complete the on-line referral form below or call 860-545-1153.



Online Referral Form

Please note the following:

  • This form is to be completed by a referring physician.
  • A representative from the Wound Healing & Hyperbaric Medicine Center will contact the patient within one business day.
 
(* = Required)
 Referral
* Type of referral:
Wound Care
Hyperbaric Oxygen Therapy
Podiatry
Reason for Referral:
 Patient Information
* Patient Name:
* Date of Birth:
* Gender: Male Female
 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
Work Phone:
Home Phone:
Cell Phone:
Primary Insurance:
  Policy #:
Group #:
Secondary Insurance:
  Policy #:
Group #:
 Referring Physician Information
* Physician Name:
Practice Name:

 Address: Street 1
  Street 2
  City      
  State       Zip
  Country
* Practice Phone:
Practice Fax:
Practice Email Address:
 Submit Your Information


Enter code shown above:
   

After submitting this form, please make sure to fax the following information to 860-545-1176. We will review this information and contact the patient to schedule his/her initial appointment.
  • Patient Demographics (Social Security, Insurance info, contact info, etc.)
  • Progress Notes
  • Medication List
  • Labs (if applicable)