Send a Message to Medical Staff - For Non-Urgent matters only

This is a secured form for the security of your personal information.

If you are experiencing a medical emergency please call 911 on your telephone.

If you have a Patient Portal account, please login to your Patient Portal account to send a secured message to our Medical Staff.

Use this form only if you do not have Patient Portal account.

Please allow 1-2 business days for a response.

Personal Information

Office Location:* --- PLEASE SELECT --- Morrisville, NC Leesville(Raleigh), NC

Patient First Name:*

Patient Middle Name:

Patient Last Name:*

Legal Guardian Name:
(if applicable)

Email Address:*

Confirm Email Address:*

Date of Birth:
(mm/dd/yyyy)*

Home Phone:  -  -

Office Phone:  -  -

Cell Phone:  -  -

Message*

* Required Fields

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All Rights Reserved. Avance Care® is a registered trademark of
Avance Health System, Inc.