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Referral by Physician Office

Referral by Physician Office

AgeWell Center serves Medicare-eligible adults 65 years of age and older. If your patient is a current Medicare recipient and is suffering from one or more of the following geriatric syndromes, AgeWell may be a good fit.

  • Decline in memory
  • Unexplained weight loss
  • Decreased mobility
  • Impaired balance
  • Frequent falls
  • Bladder or bowel incontinence
  • Depression or high-risk for depression
  • Failure to thrive
  • Compromised Instrumental Activities of Daily Living (IADL)
  • Compromised Activities of Daily Living (ADL)

In addition, if the patient has seen a downward change in status over the last 12 months (2 or more falls, emergency department and/or hospital visits), routinely takes over 10 medications (prescription and OTC), or has been diagnosed with multiple.

Fill out this appointment request form and we will call you to coordinate a date and time that works for you. All data you provide is encrypted to protect your privacy. If you would like to speak with someone during normal business hours, please call the AgeWell Center at 904.202.4243.

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Patient Information

Date of Birth (required)*

Select your birth month from the dropdown, then enter your birth day, followed by your birth year.
E.g. January 01, 1990
Gender at birth
Contact Information

Who should we contact? (required)*

Please indicate which of the following the patient has experienced

Declining Functionality:

Instrumental Activities of Daily Living Compromised:

Activities of Daily Living Compromised:

Health Events within past year:

Multiple Co-Morbidities:

Special Programs

If selecting one of these services, please also submit a physician order.
Additional Information
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