Been admitted into the hospital or ER more than three times in the past 6 months?*
- Yes
- No

Have an advanced chronic illness like COPD, heart disease, end-stage kidney disease or a neurological disease (ALS or Parkinson’s), etc.?*
- Yes
- No

Had an increase in pain, nausea, breathing problems, or other distressing symptoms?*
- Yes
- No

Begun, in the past six months, to require extra help with one or more of the following: bathing, dressing, eating, getting out of bed, or walking?*
- Yes
- No

We are here to help.

You show signs of benefitting from hospice care. Fill out the contact form below and a Hospice of the Piedmont staff member will contact you as soon as possible.

You may not be ready
for hospice care.

Although it does not appear that hospice care is appropriate for you, contact us to talk about your condition and the symptoms you are experiencing. There may be other services that can be offered to you.
First and Last Name*
Email Address*
Phone
By clicking submit, you consent to us following up with you by phone or e-mail whether you are appropriate and eligible for hospice care. If after clicking submit, you decide you do not want to be contacted any further, please e-mail us at [email protected].

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