Request Information / Make a Referral

Anyone can make a referral to Agrace HospiceCare and we thank you for thinking of us!

Living with a life-limiting illness can be challenging and we are here to help. A few things to keep in mind as you fill out this form. Please do not use the name of the person you think would benefit from Agrace HospiceCare services as this is not a secure form and we want to protect their privacy. We are happy to call you or respond to your email inquiry but cannot accept this as an "official" referral until we speak to the patient and their physician.

Fields marked with an asterisk (*) are required.

Your Name:	* Please enter a valid name.
Your Phone Number:	* (xxx-xxx-xxxx) Please enter a valid telephone number.
Email:	* Please enter a valid email address.
Comments:	Please enter your comments.	*
Please enter the security code:	If you can't read the characters in the picture above, click here Please enter a valid security code.

If you would like more information, have questions about hospice eligibility or would rather make a referral by phone, please call (608) 327-7117 in Dane and Jefferson counties and (608) 314-2917 in Green, Rock and Walworth counties.