Referrals

To refer a patient to Harris & Smith, Ob-Gyn through our website, please fill in all the fields on the secure web form below and click the submit button. The message is sent to a secure database at our practice. Our staff will make the appointment and send a confirmation back to the email address noted in the referral to our office. We hope that using this form will save you valuable staff time when making a referral to our office. If you experience any problems with the web form, please call either practice location : Capitol Street (Independence Park) 919-471-1573 or MacFarland Drive (Patterson Place) 919-967-8052, press 0 and ask for the Referral Coordinator.

Referring Provider Information
Requesting Physician Name:
Physician Address:
Physician Phone: (123)456-7890
Physician Fax: (123)456-7890
Duke Primary Care or CPDC Provider:
Email we should use to notify office appt has been made:
 
Patient Information
Patient Name:
Patient DOB:
Home Phone: (123)456-7890
Alt Phone: (123)456-7890
Insurance:
Appt Need:
   
 
Preferred Appointment Location:
 
Preferred Physician:
   
   
   
   
 
 
 
Reason for referral:
 
Please Verify Code:
(it is case sensitive)
  

 

5324 McFarland Ave., Suite 200
Durham, NC 27707
Phone: (919) 967-8052
Fax: (919) 969-8720

4116 Capitol Street
Durham, NC 27704
Phone: (919) 471-1573
Fax: (919) 471-6816

Weekday Hours:
8:00 AM - 5:00 PM
Weekend Hours: Closed

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