We Can Help
Call 24/7: 336-889-8446

Refer a Patient Patient Referral

Thank you for choosing Hospice of the Piedmont, and our affiliate Hospice of Randolph. To make a referral, complete the form below or download a referral form and return by fax.

Download Referral Form

Patient Referral

Please fill out the referral information below and someone should be back in touch with you by the end of the next business day to get the process started. If you have not heard back from the agency within 24 hours (or the next business day), please call 336-889-8446 and ask for our intake/referral nurse. Thank you again for your interest in our services.

If you want, you can also attach a scanned referral form.

  • Max. file size: 50 MB.
  • MM slash DD slash YYYY
  • Enter Name and Phone Number - 1 record per line
  • This field is for validation purposes and should be left unchanged.