Duke Children’s Specialty Services
of Wake County
Duke Medicine is dedicated to providing the best quality and outcomes for
your patients and their families, as well as discovering treatments that will
benefit young patients. We are committed to patient- and family-centered
care, which means your patients and their families will be active participants
in care, resulting in improved clinical outcomes, higher quality of care, and
enhanced patient safety.
Duke Children’s & WakeMed
Children’s Specialty Services
23 Sunnybrook Road, Suite 200
Raleigh, NC 27610
Infectious Diseases
Ann M. Buchanan, MD
Coleen Cunningham, MD
Margaret Donnelly, PA
Office 919-862-1200
Fax 919-862-1201
Referral Fax 919-862-1202
Medical Genetics
Loren Pena, MD, PHD
Allergy/Immunology
Amy Stallings, MD
Virginia Labelle, NP
Cardiology
Michael Jay Campbell, MD
Salim Idriss, MD, PhD
Jennifer Li, MD
Angelo Milazzo, MD
Christine Meliones, NP
Endocrinology and Diabetes
Deanna Adkins, MD
Kathleen Miller, NP, PhD
Gastroenterology
Megan Butler, MD
Richard Noel, MD
Yul Reinstein, MD
Narayanan Venkatasubramani, MD
Shannon Morgan, NP
General Surgery
Elisabeth Tracy, MD
Hematology
Jessica Heath, MD
Jennifer Rothman, MD
Nephrology
John Foreman, MD
Shashi Nagaraj, MD
Duke Children’s Specialty
of Cary
540 New Waverly Place
Suite 101
Cary, NC 27518
Office 919-871-1230
Fax 919-871-1228
Neurosurgery
Herbert E. Fuchs, MD, PhD
Cardiology
Brenda Armstrong, MD
Piers Barker, MD
Heather Henderson, MD
Kevin Hill, MD
Jennifer Li, MD
Stephen Miller, MD
Stephanie Burns Weschler, MD
Nutrition
Margaret McHenry, MPH, RD, LDN
Endocrinology
Deanna Adkins, MD
Plastic Surgery
Alexander Allori, MD
Gastroenterology
Narayanan Venkatasubramani, MD
Neurology & Sleep Medicine
Sujay Kansagra, MD
Pulmonary & Sleep Medicine
Richard Kravitz, MD
Jeffrey Loeb, MD
Barbara McLurkin, NP
Rheumatology
Jefferey Dvergsten, MD
Egla Rabinovich, MD
Laura Schanberg, MD
Heather Van Mater, MD
Urology
Jonathan Routh, MD
John Wiener, MD
Cynthia Camille, NP
Duke Eye Center of Cary
2000 Regency Parkway
Suite 100
Cary, NC 27518
Office 919-681-3937
Fax 919-954-4176
Laura Enyedi, MD
Duke Eye Center of Raleigh
3480 Wake Forest Road
Suite 300
Raleigh, NC 27609
Office 919-681-3937
Fax 919-862-5385
Grace Prakalapakorn, MD
Duke Orthopaedics of Raleigh
3480 Wake Forest Road
Suite 204
Raleigh, NC 27609
Office 919-862-5093
Fax 919-862-5605
Robert Lark, MD
Pediatric orthopaedic
and spine surgeon
Duke Otolaryngology of Raleigh
3480 Wake Forest Road
Suite 404
Raleigh, NC 27609
Office 919-684-3834
Fax 919-862-5733
Ear, nose and throat services;
allergy testing; audiology
Rose Eapen, MD
Eileen Raynor, MD
Duke Children’s Specialty Services
of Wake County
O F F I C E U S E O N LY
Appt Date:________/________/________
Time:__________:_________ am / pm
Request for Specialty Services
Program/Physician:__________________
Location:__________________________
RALEIGH
Patient Demographic Information
¨¨ Allergy/Immunology
Patient Name: ____________________________________ Duke History No. (If available): _______________
¨¨ Cardiology
If patient is under 18, Guardian Name: __________________________________________________________
¨¨ Endocrinology
¨¨ Gastroenterology
& Hepatology
Date: ___________________________________
Address: _________________________________________________________________________________
City: ______________________________________________ State: __________ ZIP: ____________________
¨¨ Hematology
Date of Birth: ___________________________ Gender:
¨¨ Infectious Diseases
Home Phone: _____________________ Work: _______________________ Cell: ________________________
¨¨ Medical Genetics
¨¨ Nephrology
¨¨ Neurology
M
F Race: ______________________________
Parent/Guardian E-mail: _____________________________________________________________________
Parent/Guardian Birth Date: ______________________ Does patient / family need an interpreter? Yes No
¨¨ Neurosurgery
Referral Information
¨¨ Nutrition
Reason for Referral: _________________________________________________________________________
¨¨ Ophthalmology
¨¨ Orthopaedics
¨¨ Otolaryngology
¨¨ Plastic & Reconstructive
Surgery
Pertinent History: __________________________________________________________________________
_________________________________________________________________________________________
Symptoms: _______________________________________________________________________________
_________________________________________________________________________________________
¨¨ Pulmonary
& Sleep Medicine
Referring Physician Information
¨¨ Rheumatology
Name: ___________________________________________________________________________________
¨¨ Sleep Medicine
Practice Name (if applicable): _________________________________________________________________
¨¨ Surgery (general)
¨¨ Urology
Address: _________________________________________________________________________________
City: _________________________________________________State: __________ ZIP: ________________
CARY
Office Phone: ___________________________________________ Fax: _______________________________
¨¨ Cardiology
Name of Person Completing This Form: _________________________________________________________
¨¨ Endocrinology
¨¨ Gastroenterology
¨¨ Ophthalmology
Medicaid Authorization Number (attach copy of both sides of card): ___________________________________
Patient Insurance Information
Insurance Name: ___________________________________________________________________________
Policyholder’s Name: ________________________________________________________________________
Policyholder’s DOB: ______________________________ Insurance Phone: _____________________________
Policy Number: __________________________________ Group Number: _____________________________
Please fax (using numbers on other side) with referral:
n
n
Any pertinent medical records, X-rays, ultrasounds,
or test results (films on CD)
Most recent history and physical (clinic notes)
Thank you for referring your patient to
Duke Children’s Specialty Services of Raleigh and Cary.
For immediate
assistance, please call
800-MED-DUKE
MKT-467