I understand the $100 gift car is sent to my address after my referral becomes an active Accessible Home Health Care of St. Louis patient. I confirm the person I am referring has not previously inquired with Accessible Home Health Care of St. Louis. I confirm the contact information I am submitting for my referral is accurate. I understand the gift card will be sent within 30 days of confirmed patient activation

I consent to Accessible Home Health Care of St. Louis contacting me regarding this referral via phone or email. I confirm all information submitted is accurate to the best of my knowledge