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REFERRAL FORM

For Referring Physicians Only

To refer a patient to NCOC through our website, fill in all fields on the secure web form at right and click the Submit button. The message is sent to a secure database within our clinic.

Our staff will make the appointment and send a confirmation back to the email address noted in the referral to our office.

We hope using this form will save you valuable staff time when making a referral to our clinic.

The Physicians

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 a patient referral.

Referring Provider Information


*Requesting Physician Name:
Physician Address:
*Physician Phone: (123)456-7890
Physician Fax: (123)456-7890
*DUAP or CPDC Provider:
*Email we should use to notify office appt has been made:
 

Patient Information


Duke History Number
(if available):
*Patient Name:
If you entered a Duke History # above, you do not need to enter patient demographics.
Patient DOB:
Home Phone: (123)456-7890
Alt Phone: (123)456-7890
Insurance:
*Appt Need:
   
*Preferred Physician:
*Reason for referral: