Vein Therapy 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*
Patient First Name*
Patient Middle Initial
Patient Last Name*
Patient Phone #*
Patient Cell #
Patient DOB (mm/dd/yyyy)
Patient Home Address
Patient City
Patient State
Patient Zip
Reasons for Referral Varicose veins/Vein Abnormalities
Leg Swelling
Leg discoloration/Skin changes
Leg symptoms (pain, aching, throbbing, etc.)
Authorization # If Required
Additional Information
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 919-313.5203. 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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