Patient Onboarding - Doctors Laboratory Services

AMNIOTIC TISSUE GRAFTS. If the patient's wound qualifies, amniotic membrane grafts can be applied as a biological membrane barrier that provides an extracellular matrix scaffold while supporting the patient's ability to repair underlying damaged tissue, such as acute and chronic wounds, including diabetic foot ulcers and venous ulcers.

Name(Required)

Address(Required)

Phone(Required)

Email(Required)

What insurance do you have?(Required)

Please select at least one service you need or are interested.

Medicare Only

Tricare

Medicare Advantage PPO

Neither One of these

Location of patient

Has the patient wound been treated for over 30 days?

Yes

Patients doctors name

Upload Image of Wound

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Upload image of Insurance Card

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.

Patients doctors phone number

Name of Marketing Executive

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