🎉   Introducing Formstack Sync! Learn More   🎉

Long-Term Care Referral Form Template

Simplify long-term care applications and referrals for your clients and staff.

Use This Template Preview Template

Whether you work in social services, nonprofit, healthcare, or the government sector, there's an increasing need to refer people to long-term care. With nearly 10,000 baby boomers retiring every day, the number of people who need to be placed in long-term care is growing exponentially. Simplify your referral process with this long-term care referral form. This template can also be adapted into a long-term care application.

Improve your process.

Improve your process.

No more printing out paper forms, filling them in by hand, or faxing and shredding them. This form is ready to use online, and even includes a signature field. You'll save hours on manual data entry and get rid of the many paper forms floating around the office. If your team works in areas without Wi-Fi or internet, they can still access andsubmit forms offline. Save time, money, and resources by implementing Formstack for any of your data capture needs.

Safely and securely store data.

Safely and securely store data.

Collect and share personal healthcare information across any device, while keeping patient data safe and secure with our HIPAA compliant solution. Formstack encrypts data and safely stores it in a database, keeping your organization compliant with HIPAA regulations. With this patient referral form template, you have full control over who views the information and can track user activity. We also provide HIPAA compliant integrations to simplify your healthcare data collection.

Simplify your data management.

Simplify your data management.

Gain greater insight into the population you serve with in-depth data from form submissions. Powerful analytics tools allow you to visualize your data, compare submissions, track trends, and more. Use this form to track referrals, understand year-to-year changes, and where your staff is making the most (or least) referrals. Utilize your dashboard to get quick insight on what forms are being completed and streamline your everyday processes.

Easily export data.

Easily export data.

Need to share data with family members, healthcare facilities, or other agencies? Easily send information through email, via a simple link, or by exporting your submissions. Formstack makes it incredibly easy to export data into CSV, Excel, Word, or PDF format. With a multitude of integrations, you can automate data sharing with tools like Google Sheets, Salesforce, or WebMerge. It's also simple to streamline communication with your team, patients, and referral agencies by setting up automated email notifications triggered by form submissions.

Social Proof

"Formstack enabled us to create an online form, complete it with a signature, create a PDF for our paper files, and import a CSV copy directly into our database."

Daniel Marlay,
Make-A-Wish Greater Bay Area

Ready to get started?

Get access to this long-term care referral template and other healthcare forms immediately by starting a free trial.

Get This Template

Discover more templates.

Browse our template collection by category and type.