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REFERRAL FORM

For Patients Only

To request an appointment through our website, fill in all required fields n the secure web form at right and click the Submit button. The request is sent to a secure database within our clinic.

Our staff will contact you at the preferred number you provide to schedule your appointment and provide you with a confirming email.

We hope using this form will save you from the frustration of reaching our office during periods of high call volume.

The North Carolina Orthopaedic Clinic Lobby

Request an appointment coordinator to contact you to schedule an appointment.

If appointment request is for an injury/condition resulting from a Work Injury, do not use this form. Please follow instructions below:
For work injuries, call the Duke WC office at 919-684-2848
Once the visits are authorized at this number they will schedule the appointment in our clinic.

Items with an asterisk (*) must be completed to submit an appointment request.
*Full Patient Name:
*Email Address:
*Preferred Phone Number: (123) 456-7890
*Preferred Physician:
Preferred Weekday for Appt:
Preferred Time for Appt:
*Insurance Carrier:
*Patient Date of Birth:
Referred By:
*Best time to contact you at the phone number provided above:
 
*Please check one of the following:
 
 
*Briefly describe the reason for your visit:
 
Our appointment coordinator will contact you within 24 hours to schedule your appointment.

Please bring the following to your appointment:
  • All relevant x-rays, CTs, MRIs
  • List of all current medications
  • Insurance card
  • Co-pay (if required)
Request Information: