Hammond-Henry Hospital

Refer Someone to Home Health Services

We appreciate your confidence in Hammond-Henry Hospital Home Health Services to provide you with personal and professional care.

If you or someone you know needs medical help in the home and you would like to know if you qualify for these benefits, please complete the form below. Please provide your contact information and then tell us as much as you can about the patient's home care needs so we may best respond to your inquiry.
How did you hear about us:
This inquiry is for: *
Your first name: *
Your last name: *
Address: *
Address (continued):
City: *
State / Province: *
Postal Code: *
Home Phone: *
Alternate Phone:
Email Address:
Comments and Questions:
Patient's First Name: *
Patient's Last Name: *
Has patient previously received home care services:
If so - when:
Use Telephone:
Get out of bed unassisted:
Walk unassisted:
Operate a motor vehicle:
Shop for essentials:
Handle money / pay bills:
Prepare Meals:
Eat unassisted:
Do routine housework:
Do laundry:
Dress and undress self:
Shower/Bathe/Groom self:
Get to toilet in time:
See physician frequently:
Follow medical directions:
Have prescribed medications:
Have diabetes:
Receive home health:
Have a physician:
Have physician ordered therapies:
Have adequate informal support:
Seem confused:
Have ability to share in cost of care:
Recent changes in medication:
Recently Hospitalized:
Any wounds:
If so - where:
Recent new diagnosis:
If so - what:
Security Code:
Enter the code shown above in the box below
* required