Rehab Medicine Referral Form

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.

Type of referral request Consult for Pain Management
Epidural Steroid Injection: Cervical Thoracic Lumbar
EMG - body part
Second Opinion
Behavioral Pain Management
Psychological Clearance for procedure
Other:
Diagnosis
Physician Preference
Location
Referring Physician
Referring Contact Person
Referring Contact Phone/Fax #
Patient Name
DOB
Home Phone #
Work Phone #
Cell Phone #
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 919-281-8998. Once the records are received we will contact the patient to schedule the appointment.

Yes

"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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