ONLINE REFERRAL FORM
Burke Hospice & Palliative Care

Thank you for making a referral to Burke Hospice & Palliative Care. Entries on this form are stored on a secure server and are processed by our Intake Coordinator. If you prefer to make a referral by phone, call Burke Hospice at 828/879-1601 and ask for the Intake Coordinator.

Note: Fields marked with * are required.
I would like to refer this patient to: * 

Patient's Information

Gender *
Is the Patient currently staying at home? *
If "No," where is the Patient currently located?
 



0/1000 characters

Referrer's Information

I am making this referral as a/an... *
 

Referral Survey (Optional)

Answers to these last three questions help us better understand how patients and referral sources are connecting with our services. If you prefer not to answer, please scroll to the bottom of the page and click the "Submit" button to send your referral to the Intake Coordinator.



How did you or your organization first hear about Burke Hospice? (optional)
 
Have you, or your organization, ever referred to Burke Hospice before? (optional)
If "Yes," how would you rate your satisfaction level with your previous referral to us? (optional)


Thank you again for your referral.
Our goal is to respond to all referrals in the same business day.

If you have questions about the Patient or this referral, please call us at 828/879-1601 and ask for the Intake Coordinator. If you have questions or problems concerning this form, call 828/879-1601 and ask for the Webmaster, or email info@burkehospice.org.

To complete this referral, please click the "Submit" button below. 
Burke Hospice & Palliative Care | 1721 Enon Road | Valdese, NC  28690 |www.BurkeHospice.org