Are you a clinic or provider making a referral? Please
refer a patient
instead.
Request Appointment
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Is this urgent?
If so, please call us at
919-752-7335
Otherwise, please click "Next".
Who is the patient?
Patient first name
This field is required.
Patient last name
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Date of Birth
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Reason for Request
Upload documents (optional)
You can securely upload a referral letter, clinic notes, photos.
You may also fax documents to us at 919-924-0275
How can we reach you?
Your First Name
Your Last Name
Date of Birth
This field is required.
Email
Phone
Preferred appt time
Morning
Midday
Afternoon
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