New Patient Referral Form (for referring physicians)
New Patient Registration Forms
New patients, please download, complete, and return this form to the office before your appointment. You may do so by mail or fax. If you fax please bring originals with you.
Our fax # 336-272-8495.
Mail to : P.O. Box 4428,
- Please include copies of your insurance cards (front and back) with your forms.
- Many policies require the patient to make a co-payment. Please be prepared to take care of this as you check in with the Receptionist.
- If your insurance requires a written referral, please bring this with you. If you are not sure if you need one, call your primary physician and they will let you know. If your insurance requires one and you do not bring it with you, you will be asked to pay for your visit.
- Worker’s compensation injury- this requires a written verification and billing information from your employer. Without this, you will be responsible for payment.
- Please be sure to have your driver’s license with you. We will make a copy for your chart. This is for identification purposes to prevent insurance fraud.
- You must bring any x-rays or MRI films or other test results. No CD’s accepted in place of actual films. Failure to do so may require your appointment to be rescheduled.
If you have any questions regarding your appointment, please call 336-272-4578
Michele at extension 220
or
Linda at extension 225
