Are you a clinic or provider making a referral? Please
refer a patient
instead.
Request Appointment
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2
3
At this time, we are not taking new patients in order to serve our existing patients and urgent referrals from physicians.
Is this urgent?
If so, please call us at
919-752-7335
Otherwise, please click "Next".
Who is the patient?
Patient first name
This field is required.
Patient last name
This field is required.
Date of Birth
This field is required.
Reason for Request
When did you first notice the problem?
Is the problem getting better, worse, or staying the same since it started?
Please upload any
pictures
or video that you think will help the doctor.
Please upload any
documents
that you think will help the doctor.
How can we reach you?
Your First Name
Your Last Name
Date of Birth
This field is required.
Email
Phone
Preferred appt time
Morning
Midday
Afternoon
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