New Patient Form

At AWC Accelerated Wound Care, we’re dedicated to building strong, streamlined connections between patients, primary care providers, and our expert wound care specialists—whether treatment takes place in-office or in the comfort of your home.

Response Time: 24 hours

Patient Visit Turnaround Time: Within 72 hours

To help us deliver the most effective care, please complete the secure, HIPAA-compliant form to the best of your ability. The information you provide allows our team to better understand your medical background and customize your wound care plan to fit your specific needs.

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Street Address *

Street Address Line 2

City *

Postal / Zip Code *

Primary Care Physician

Provider First Name *

Provider Last Name *

Provider Phone

Provider Fax

Secondary Contact

Secondary Contact Name

Secondary Contact Phone

Relationship

Insurance Information

Insurance Provider *

Policy Number *

Secondary Insurance Provider

Secondary Policy Number

Trusted Mobile Wound Care, Right at Your Door

Skip the clinic — let expert care come to you. Browse our network of certified wound care specialists and connect with a provider near you for professional treatment in the comfort of your home.

Accelerated Wound Care – Serving the Chicagoland Area

Phone: (844) 292-5708

Fax: (244) 361-2616

Email: Info@AWCIllinois.com

2720 S. River Rd., Suite 256

Des Plaines, IL, 60018