Hospital Referral Form

Staff from UNC Hospitals or an affiliated clinic must make the initial referral. To make a referral, please download and save the paper form (linked below) to your computer.

To type directly into the Adobe PDF Form:

  • Be sure to update your Adobe Reader to ensure it displays properly
  • Save the blank form to your computer before filling it out
  • Complete all fields–incomplete forms will be returned to you
  • Save the form again
  • Send the completed form as an email attachment to

If you prefer to fax the form or have difficulties typing into the Adobe form:

  • Save the blank form to your computer
  • Print it
  • Complete all fields in clear handwriting–incomplete or illegible forms will be returned to you
  • Fax it to our office at 919.918.3830.
  • If you have any questions, please call Janice Ross, House Manager, at 919.932.8019

Paper Referral Form*

Information Packet for Hospitals

Information Packet for Families 

Guest Policies and Information 

*Note: If you are unable to type into the Paper Referral Form, try updating your Adobe Reader program. Be sure that you save it before you type into it, too, or you will lose your work.