Request Services

Where Do I Start?

Anyone can refer a patient for a hospice or palliative care evaluation. The form below is intended for use by patients, family members or friends. 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 888-283-1722.

If you are a healthcare professional, please click here for the referral form.

Which type of service are you requesting?: *

Patient's Information:

First Name: *
Last Name: *
Date of Birth:
Current Location: *
Telephone: *
Diagnosis:

Primary Care Physician

First Name: *
Last Name: *
Telephone: *
Additional Physician Following Patient (if known):
First Name:
Last Name:
Specialty:
Telephone:

Your Information:

First Name: *
Last Name: *
Telephone: *
Email:
Relationship to Patient *
Is the patient aware of your inquiry for a consultation? *
Who is the best person to coordinate the appointment with? *
First Name: *
Last Name: *
Telephone: *
Relationship to Patient *
Please provide any pertinent information that prompted you to reach out to Care Dimensions for this patient:
How did you hear about Care Dimensions? *
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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 more than 90 communities in Eastern Massachusetts.