Refer A Loved One

Thank you for considering Amity Care Hospice services in caring for your loved one.  We recognize how challenging it can be to make a call such as this.  We want you to know that we are honored by your request and will do our best to provide the love and compassion that you want for your loved one.  You can reach us by calling 678.402.5235.  Your call is important to us and, in order to assist you, it would be helpful if you could have the following information handy:

  • Your name
  • Your relationship to the person who needs assistance
  • The best time to contact you
  • Your most pressing concerns or needs whether it be:
  1. Pain and/or symptom management
  2. Help with medication
  3. Help in understanding the illness
  4. Assistance with self-care (bathing, dressing, eating, etc.)
  5. Support for family
  6. Making decisions about care options
  7. Help with coping emotionally or any other concerns
  8. Location of the person needing assistance
  9. Their physician’s name and phone number.

If you wish, you can also email that information to our Clinical Director, Valerie Tapper, RN, BSN, CHPN, at

Again, we welcome the opportunity to serve you and those you love.  In the midst of this transitional time, we wish you peace.

Patient's First Name  :  *
Patient's Last Name  :  *
Your Email  :  *
Street  : 
Street2 (optional)  : 
City  : 
State  : 
Zip  : 
Patient's Phone Number  :  *
Attending Physician  : 
Primary Diagnosis  : 
Caregiver's Name  : 
Relationship  : 
Caregiver's Phone Number  : 
Your Name  :  *
Your Return Telephone Number  :  *
Your Relationship to the Patient  :  *
Comments  :