Web Referral for Bariatric Surgery

Referring physician offices can now upload patient records when submitting web referrals. Click link on the bottom of the page to upload records and orders.

Referring Physician*
Referring Contact Person*
Referring Contact Phone*
Referring Contact Email*
Referring Contact Fax*
Patient First Name*
Patient Middle Initial
Patient Last Name*
Patient Home Phone #*
Patient Cell Phone #
Patient Work Phone #
Patient Email*
Patient DOB (mm/dd/yyyy)
Patient Height
Patient Weight
Patient BMI
Comorbidities Hypertension
High Cholesterol
Sleep Apnea
Authorization # If Required
Click Here To Attach Patient Records
(PDF, DOC/DOCX and JPG file types accepted)

Thank you for your referral. If you are unable to upload office notes, please fax all office visit notes, labs, diagnostic reports and any other records to our office at 919-234-4475. Once the records are received we will contact the patient to schedule the appointment.

"Being able to access your Orthopedic Urgent Care on a Saturday was a God-send. It was wonderful to avoid an ER. Thank you all so much for being open on Saturdays and after hours, Monday through Friday."

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