Pediatric Patient Self-Referral

By completing this form, you can start the process of working with us to decide on a plan that is best for your patient.

All messages (phone and online forms) are checked regularly during business hours. We will respond to each message. However, due to the high volume of incoming calls and messages we receive, we ask that you please allow up to three business days for our response.

Our online forms are sent to us via email. Please note that email does not provide a completely secure and confidential means of communication, as it is possible, although not likely, that an unauthorized 3rd party may be able to intercept and view email messages. If this is a concern for you, please do not use this form and instead call our main telephone number, 919-684-5301. For more information, please review Duke Health's Notification of Privacy Practices, and our Website Privacy Policy.

Information about the pediatric patient's parent/guardian

Information about the patient

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