Easy Referrals, Fast Care

Our Promise of Care

Compassion First

We treat every patient with dignity, kindness, and empathy.

Expert Care

Skilled wound care tailored to each unique healing journey.

Accessible Service

Mobile wound care that meets patients where they are.

Holistic Healing

Supporting both body and spirit through recovery.

A Referral Process Built Around You

At Mend & Restore, we believe healing shouldn't wait. That's why we've made our referral process as simple and seamless as possible - so patients can get the compassionate, skilled wound care they need without delay.

Whether you're a physician, case manager, or family member, referring a patient takes just a few steps. Our team handles the rest, coordinating care with heart and precision from the very first call.

Submit referrals securely online by completing our referral form below.
You may also send us an email directly by clicking "Refer a Patient Today" button.
Call us directly and we'll take care of the paperwork.

Have questions or need to schedule an appointment? Contact us today to speak with one of our friendly staff members.

Refer a Patient Today

Referral Form

Fill Online

Complete and submit the referral form directly from your browser.

Download & Email

Download our referral form, fill it out, and email it to hello@mendandrestore.com

Download Referral Form

Patient Referral Form

Referring Provider Information

Provider Name

Practice / Facility Name

Phone Number

Fax Number

Email Address

NPI Number

Patient Information

Patient Full Name

Date of Birth

Phone Number

Home Address

Email Address

Emergency Contact Name & Phone

Insurance Information

Insurance Provider

Policy / Member ID

Group Number

Wound Care Details

Reason for referral (select all that apply):

Wound Description & Location

Additional Notes or Instructions

Provider Signature

Printed Name

Date