Hospice & Palliative Care Referrals

If you are interested in receiving services for yourself, a family member, or a loved one, please fill out the form below.

For privacy and safety reasons, please do not include any personal health information. If you have questions, need more information, or require immediate assistance, please call us at 803-329-1500.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Best time to call?

I am requesting information/services for:

I am interested in discussing:

How did you hear about us?

Message

Physician Referrals

There are two simple ways to refer your patient to Hospice & Community Care:

Fax: (803) 329-1695
- Please Include with your fax:
  - Fax Cover Letter
  - Referral Form
  - Patient Demographic Sheet
  - History and Physical (H&P)
  - Progress Notes
  - Medication List
Call: (803) 329-1500