Orthopedic Referral Form

Thank you for choosing EmergeOrtho Triad Region for your orthopedic referrals. We value our relationships we have with referring providers. This page is designed to best serve referring providers and referral coordinators when referring a patient to EmergeOrtho Triad Region.

To schedule an appointment with one of our physicians, please choose 1 of the following options.

Option 1: Submit the form below. Before submitting this referral form, please, click the link at the bottom of the page to upload patient records and orders. If you need assistance, please call our appointment line at 336-545-5001 or email us at referrals.triad@EmergeOrtho.com

Option 2: Complete & Fax our Patient Referral Form – Triad Region, attaching patient demographic information and office notes. One of our appointment representatives will contact the patient directly to schedule their appointment.

Option 3: Call our Appointments department at 336-545-5001 – to speak with our one of appointment representatives.

Thank you for your referrals.