You can download a printable copy of our referral form and fax the completed form to our Holly Springs hospital at 919-887-6911 or you can submit your referral or transfer using the online submission forms below. 

If you complete an online referral form, please call our Holly Springs hospital at 919-973-5620 to inform us that you have submitted the form.

Printable Form

Online Form

EMERGENCY REFERRALS *
PLEASE DO NOT USE THIS FORM FOR EMERGENCY REFERRALS. INSTEAD CALL OUR OFFICE AT 919-973-5620 TO SPEAK DIRECTLY TO A CLINICIAN.
Type of outpatient ultrasound requested
If referring to Outpatient Ultrasound service
Hospital Phone Number *
Hospital Phone Number
Client Name *
Client Name
Client Phone *
Client Phone
Species *