Hospice Referral Form

Download Referral Form

Healthcare professionals, family members, friends, or patients themselves may request Hospice services. All patients must have an attending physician′s certification of prognosis for admission to the program, but the initial referral can come directly from someone close to the patient.

Hospice admission criteria require a six-month prognosis, but too often patients are referred in the last weeks or even days of their lives. The earlier a patient is admitted to the program, the greater the benefit to the patient, caregiver, and family.

We appreciate your interest in care from Hospice of the Piedmont. Please call us for more information anytime during normal business hours (Monday through Friday, 8 a.m. to 5 p.m.) at 336.889.8446. After hours or on weekend, please leave a message and we will get back to you within 30 minutes.

To fax in referral information, please download our referral fax and include the following items:

  • History and physical (H&P) form/FL2/hospital discharge summary for the patient
  • Copy of the patient’s demographic (face) sheet
  • Medication list
  • Progress notes or other documentation
  • Physician order for Hospice consultation

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