First Name *

Last Name *

Phone *

Email *

What kind of wound are you currently dealing with? *

Diabetic foot ulcer

Surgical wound that’s not healing

Pressure sore (bed sore)

Leg ulcer or vein-related wound

I’m not sure / just a sore that won’t go away

What kind of insurance do you have? *

Medicare

Medicaid

PPO

HMO

Other

How long has the wound been present? *

Less than 2 weeks

2–4 weeks

Over 4 weeks

Not sure

Which of these apply to your wound? *

Pain or burning sensation

Swelling or redness

Draining or bad smell

Growing or getting worse

None of these

Do you have any of the following health conditions? *

Diabetes

Poor circulation / vascular disease

Recent surgery

Limited mobility

None of these / Not sure

What is your zipcode? *

Do you prefer to receive care in our clinic or at your home? *

In-Clinic Visit

In-Home Visit (Mobile Care)

I agree to be contacted by Bio Liv about my wound care options. *

Yes

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