Refer a Patient - Care Dimensions

Keeping You Safe During COVID-19 

Learn More

I'm looking for

Refer a Patient

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.

Anyone—patient, family, care provider—can make a referral. Fill in the form online or call us today.

Since 1978, Care Dimensions 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.

Copyright 2022 | Care Dimensions, 75 Sylvan Street, Suite B-102, Danvers, MA 01923 | 888-283-1722 | 978-774-7566

Privacy | Terms of Use

We use cookies and other tools to enhance your experience on our website and to analyze our web traffic. For more information about these cookies and the data collected, please refer to our Privacy Policy.

Accept