Refer a Patient

The form below is intended for use by healthcare professionals. Once your form is submitted, someone from our Referral Center will follow up with you. If you prefer to speak to someone immediately, you can call us at 888-287-1255 for hospice; 888-283-1433 for palliative care; or 888-281-0011 for HomeMD. The Referral Center fax number is 978-774-4389.

Referring Physician:

First Name:*

Last Name:*

Telephone:*

Patient's Information:

First Name:*

Last Name:*

Date of Birth:*

Current Location:*

Location Detail:

Telephone:*

Diagnosis:

Which type of service are you requesting?:*

Please attach in one file (PDF, zip file, etc.): insurance information, history and physical exam notes, labs. If you cannot attach a file, please fax information to 978-774-4389 and reference patient name.

How would you prefer to be contacted after this visit is made?*

Contact method info (email, pager, phone):

Person completing this referral (if different from above):

First Name:

Last Name:

Telephone:

What is your role in relation to the referring physician?

Does the referring physician approve this request for evaluation?*

Is the patient aware of your inquiry for a consultation?*

Who is the best person to coordinate the appointment with? :

If patient, select the check box.

First Name:

Last Name:

Telephone:

Relationship to Patient:

Other:

Describe the circumstances of death, including the cause of death and when the death occurred:

For verification purposes click the button below.

Since 1978, Care Dimensions, formerly Hospice of the North Shore, has provided comprehensive and compassionate care for individuals and families dealing with life-threatening illnesses. As the non-profit leader in advanced illness care, we offer services in over 100 communities in Massachusetts.

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