This form can be utilized to make a patient referral.

Please print form and complete the indicated information and fax to:
CCPGM Referral Form

Office hours:
8 a.m. - 5 p.m., Monday - Friday

Phone:
704-512-5555 (phone)
704-512-2290 (fax)
1-888-671-7437 (toll-free)

Email:
CCPGM@carolinas.org