Knoxville Wound Care — Medical Reconciliation Form

University Wound Care and Hyperbaric Center

Prior to your visit to the Wound Care Center, please complete the Medical Reconciliation Form and the Patient History Form online. If you have any questions, please contact our office at 865-305-5510.

Knoxville Office Wound Care — Medical Reconciliation

University Wound Care and Hyperbaric Center medication reconciliation form

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Pharmacy of Choice(Required)

Pharmacy Phone Number(Required)

Pharmacy Fax

Allergies/Adverse Reactions/Sensitivities(Required)

Please name all allergies (medication, food, etc.) and describe the type of reaction, such as rash, itching, difficulty breathing, etc.

List All Prescribed Medications(Required)

Please list all medications prescribed, including dose, frequency and purpose.

List All Over-the-Counter Medications(Required)

Please list all over-the-counter medications. Include dose of medication, frequency and purpose. Also, please list all vitamins and supplements, including herbal and natural.

Contact Info

University Wound Care and Hyperbaric Center
1924 Alcoa Highway
Medical Building E, Suite 40
Knoxville, TN 37920
Phone: 865-305-5510
Fax: 865-305-5515

Find a Doctor

Contact Info

University Wound Care and Hyperbaric Center
1924 Alcoa Highway
Medical Building E, Suite 40
Knoxville, TN 37920
Phone: 865-305-5510
Fax: 865-305-5515

Find a Doctor

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Knoxville Wound Care — Medical Reconciliation Form

Knoxville Office Wound Care — Medical Reconciliation

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