Surgical Specialists 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.

Referring Physician*
Referring Contact Person*
Referring Contact Phone*
Referring Contact Fax
Referring Contact Email*
Reason for Referral
Patient Name*
DOB (mm/dd/yyyy)
Home Phone #
Work Phone #
Cell Phone #
Type of Insurance
Authorization # (if needed)
Appointment Date & Time
Physician Preference
Specialty Gallbladder
Hernia
Colon
Skin
Thyroid
Breast
Adrenal/Spleen
GERD
Abdominal
Other:
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 919-627-6125. 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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