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).

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

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