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ApexSkin – Advanced Mobile Clinic
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Intake form
Help us serve you better
Name
*
Email address
*
Phone number
Preferred contact method
Select
Phone
Email
Type of wound
Please select at least one option.
Diabetic foot ulcer
Pressure injury
Surgical wound
Venous ulcer
Severity of wound
Select
Mild
Moderate
Severe
Current treatment regimen
Location for service
Insurance provider
Select
None
Medicare
Medicaid
Blue Cross Blue Shield
Aetna
Cigna
United Healthcare
Referral source
Select
Self
Physician
Friend/Family
Internet
Preferred appointment date
Preferred appointment time
Additional questions or comments
Submit
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