Referral Form

Welcome to North Carolina Hospital Dentistry (NCHD).  Our primary focus is treating Dental Patients with General Anesthesia at the hospital.    Please complete the referral form and we will respond.  Cases are completed at WAKE MED Hosptial (New Bern AVE, Raleigh, NC).

Contact Name:

Patient's Date of Birth :

Contact Phone Number :

Contact Email :

Reason for Hospital  Referral :

Are you in dental pain now?: