New Patient Referrals

If you are from a doctor’s office and would like to refer a patient for a new patient appointment, please fill out the information below. Then, please fax the doctor referral and/or recent/relevant patient visit notes to 919-301-0786, as well as the patient’s demographic data (Name, DOB, Home Address, Insurance information, Phone #).

Typically, our earliest available new patient appointment slots are 1 – 1.5 months from the date of appointment request. New Patients are seen everyday of the week except for Friday, and are scheduled for 7:30 am, 8:30 am, and 1:30 pm slots.

To refer a new patient to be scheduled for an appoinment with us, please fill out the form below. Our scheduling coordinator will contact you to confirm your appointment. This site is NOT monitored for emergency care. Please call 911 if you are experiencing an emergency.

Patient’s last name: *

First: *

Middle: *

Street address: *

City: *

State: *

Zip code: *

DOB: *

Email: *

Phone: *

Reason for consult :

Primary Medical Insurance (and secondary/tertiary insurances if applicable). Please put in the Plan ID/number, Group number (if applicable), and dates issued for each : *

Referring Doctor Name and Phone Number : *

Clinic Practice Name and Location : *

Preferred Appointment Time : *