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Iowa City Hospice

Refer A Patient

To refer a patient to Iowa City Hospice or to request services for yourself, please complete this form. During normal business hours (Mon–Fri, 8AM–5PM CST), contact Iowa City Hospice at:

Fax: 319/351-5729

If you have an immediate need, please call the numbers above. If it is after hours, you will be given an emergency number to call.


To request services, please complete this form. All fields marked (*) are required.

Your Information

Your Name*

Your Email*

Please indicate how you know the person who needs assistance*

Person Who Needs Assistance

Full Name

Contact Information For Person Needing Assistance

If we should contact someone other than the person in need of assistance (caregiver, family member, healthcare professional), please indicate below.

Full Name

Phone Number

Please indicate the relationship of this contact person to the person being referred.

What is the best time of day to contact them?

Additional Information

What are your most pressing concerns or needs? (Please check all that apply.)
Pain and/or symptom management
Help with medication
Help in understanding the illness
Assistance with self-care
Support for family
Making decisions about care options
Help with coping emotionally

What is the current location of the person needing assistance? (Or what is your current location?)

Current Doctor's Information:

Full Name

Phone Number