Refer a Patient for Services Please use the form below to contact us about patient services. Someone from our facility will contact you shortly. Thank you for your interest in Farmington Country Manor Nursing and Rehabilitation! Date Provider Name: First Last Provider Phone Number:Patient Name: First Last Date of Birth: Please check all of the services that you are in need of: Skilled Nursing Rehabilitation Outpatient Therapy Long-Term Care End of Life/Hospice Respite or Vacation Care When is this service needed?ASAPA week from nowA month from nowotherIf you checked "other" from above, please explain when you need these services. This iframe contains the logic required to handle Ajax powered Gravity Forms.