Referral by Physician Office

Referral by Physician Office Main Content

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.

Contact Information

Please indicate which of the following the patient has experienced:

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

Additional Information

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Referral by Physician Office Confirmation

Thank you for submitting your request to refer a patient to the AgeWell Center for Senior Health. AgeWell staff will be contacting you by phone within the next business day to discuss your request.

Please Note: This service is only for NON-emergency referrals. If your patient has a medical emergency, please call 911.