Physician Referral Form

If you are referring yourself, a family member, or a loved one, please fill out the "Contact Us" form. Check the box for information about referral.

Thank you for considering care from Hospice & Palliative Care Charlotte Region. During normal business hours, we will respond to your inquiry within four hours or less.  For referrals after normal business hours and on weekends, please call 704.375.0100.

Along with this referral form, please fax the following items:

  • History & Physical Form (H&P) for the patient
  • Copy of the patient’s demographic sheet (face sheet)
  • Progress notes or other patient documentation

  
If you would like immediate assistance, please call us at 704.375.0100