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.

If you are a physician, please fax the following items to 704.335.3522, along with the referral form found here.

  • 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

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.