Referral Form

Welcome to North Carolina Hospital Dentistry (NCHD).  Our primary focus is treating Dental Patients with General Anesthesia at the hospital.    Please have the patient type their email address in the box below  Cases are completed either at Duke Regional, Duke Raleigh, DASC, or WAKE MED Hospital (New Bern AVE, Raleigh, NC).  Email is mandatory and required for communication.   Patient must complete paperwork within 30 days of referral.  Tell your patients to expect an email within 24 hours of referral

Patient's Name:

Patient's Date of Birth :

Contact Name / and Number

Patient's Email

Reason for Hospital  Referral :

Are you in dental pain now?:

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Dental Services Requested

Referral Doctor

Referral Doctor Email

Upload Radiographs
Upload Treatment Plan
Upload Radiographs

Steps to having this done: 

1. Referral Submission

2. Sign the electronic medical history form (Adobe Sign) Emailed

3. Make an appointment with your primary care physician for a history and physical.  Form can be downloaded here: 

4. Schedule the procedure within 30 days of completed history and physical.    

- You have 30 days to complete the paperwork. 

- We communicate via email

- Only for motivated patients 

Thanks for submitting!

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