Required fields are marked with an asterisk *. First Name *Last Name *Date of Birth *Phone Number *Location of Injury *Was this a work related injury? * Yes NoInsurer *Policy Number *Group Number *PLEASE NOTE: You are responsible to verify with your insurance that Swedish Medical Center and the Burn and Reconstructive Centers of Colorado are considered to be IN-NETWORK prior to your visit. Rate Your Experience Submit Your form has been securely received! There was an error with the form submission.