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.

Upload Scanned Referal Form
Max. file size: 50 MB.
Referral Type
- Patient or Family Referral
- Healthcare Provider Referral
Salutation
- Mr
- Mrs
- MS
Referrer's Name*
First Last
Relationship to Patient*
Email*
Phone*
Patient's Name*
First Last
Patient's Date of Birth
MM slash DD slash YYYY
Patient's Diagnosis
Patient's Current Location*
Patient's Physicians
Enter Name and Phone Number - 1 record per line
Comments
This field is for validation purposes and should be left unchanged.

Your entire team was amazing. They are very professional in their work but also have big hearts and it comes through in how they do their work and in their positive attitudes.

- Daughter of patient

Thank you for making your home like her home, warm and comfortable.

- Sister of a patient (in reference to Hospice Home)

Your kindness and efforts go far beyond the patients and extend to their families and friends.

- Family of a patient

Everyone who cared for my wife was, without exception, caring, kind, and exceptionally capable individuals who seemed to truly care about her well-being and care.

- Husband of a patient

Your staff (at Hospice Home) was confident, thoughtful, kind and very loving to my mom. When we couldn’t be there or take care of her needs, you took care of her.

- Son of a patient

My mother spent her last days in your facility. I want to thank you for the gifts you gave to her and our family. The dignity, caring, professionalism, and kindness will remain a bright part of our saying goodbye to our mother.

- Daughter of a patient

My family and I would not have made it without Hospice.

- Daughter of a patient

For many veterans, military service is the most important thing that they have done in their lives.” As part of We Honor Veterans, those patients are now paired with a volunteer who also served in the military and share a common bond.

- Joe Lyons, Hospice volunteer

Thank you for all of your care, concern, education and kindness during Mom’s last year. My grief journey has had a lighter backpack because of Hospice.

- A patient’s daughter

Their touch, their time, their words were the comfort of a lifetime.

- A patient’s family

We were privileged to have the support of (Hospice)…They nurtured and cared for my husband as if he was their only patient.

- Wife of a patient

Me consuela saber que mi esposa tuvo los mejores cuidados gracias a Hospice. La ayudaron a ella y a nuestra familia en todas las maneras posibles.

- Marido de un paciente

I thank God for putting good people in the right job for people like me.

- Patient family member

We were so impressed by your staff and your desire to help us. No one wants to need Hospice, but when a person does, it is a tremendous blessing. Thanks again for the care you gave my dad, and ultimately all of us.

- Daughter of a patient

I would like to say that you have a beautiful Hospice Home. It is so nice and serene. I love the “quiet spots” that you can go to and meditate. Thank you so much in helping make my mother’s last days on this earth a little better and comforting.

- Daughter of a patient