Referral Form

Client Name

Please complete the following if applicable

Referred by

If you have an emergency reproductive need, please call the office at 336-940-3442 for fastest service

Our staff members will reach out to the client within 3 business days to schedule an appointment with Dr. Nebel-Karp after you have completed the referral. The consult fee is $125.00 and is a 30-40 minute appointment to assess the individual needs of our mutual patient. We will then provide an estimate for future services.

Any routine general services, labs and immunizations need will not be performed at AHED. Thank you in advance.