This page is designed for physicians to refer their patients to OSNC physicians for consultation. For patient appointments click here.

If you need to have your patient seen in an expedited manner and cannot call our referral coordinator, please download the Referral Pad, complete and submit to our office with the patient for review.

Click Here for Referral Pad (Downloaded in Adobe Reader File -- .pdf)

Or you may complete the form below:

Items with a red asterisk (*) must be completed to submit physician referral.

Physician: *

Mark W. Galland, M.D. Orthopaedic Surgery & Sports Medicine

Clifford R. Wheeless III, M.D. Orthopaedic Surgery

Paul B. Suh, M.D., Surgical & Nonoperative Treatment of the Spine

Lawrence J. Yenni, M.D. Orthopaedic Surgery

Cary Idler, M.D. Surgical & Nonoperative Treatment of the Spine

Ingrid Luo-Tseng, M.D. Physical Medicine & Rehabilitation, Pain Management

Derek Watson, M.D. Physical Medicine & Rehabilitation, Pain Management

Patient Full Name: *

Diagnosis: *

Notes/ Mechanism of Injury:

Patient Email Address:

Patient Daytime Phone:

Patient Evening Phone:

Patient Address:

Preferred Appt. Day: select...MondayTuesdayWednesdayThursdayFriday

Preferred Appt. Time: select...8:00 AM - 10:00 AM10:00 AM - Noon1:00 PM - 3:00 PM3:00 PM - 5:00 PM

Preferred Appt. Location: select...Wake ForestNorth RaleighHendersonLouisburgKnightdaleChapel HillOxford

Insurance Provider:

Carolina Access Number:

(if applicable)

Referring Provider: *

Provider NPI Number: *

Provider Phone Number: *

Provider Fax Number:

Additional Materials are Available for Review, Check All That Apply:

X-Rays

EMG

MRI

U/S

CT

Labs

Bone Density

Other Information Not Listed

Please provide and instruct the patient to bring all relevant X-rays, CT's, MRI's, and/or other relevant tests

ID#:

Group#:

Claims Address::

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