The Epilepsy Institute of North Carolina
accepts most major insurance plans.

No need to worry...
the Epilepsy Institute of North Carolina
is here to help!

Call for an appointment

J. Christine Dean, MD
Co-Founder & Director
  North Carolina Licensed
  North Carolina Certified  Specialist


1311 Westbrook Plaza Drive
Suite 100
PO Box 24458
Winston Salem, NC  27114-4458
(336) 659-8202
FAX:  (336) 659-8206
email: info@eiofnc.org
EPILEPSY INSTITUTE OF NORTH CAROLINA
The Brain is ...  Where You Live
COMPREHENSIVE EPILEPSY PROGRAM                                           PATIENT CARE • EDUCATION • RESEARCH                                                  BEHAVIORAL HEALTH CENTER                                            THE BRAIN IS WHERE YOU LIVE

Patient Referral Forms


Please download and use the provided form below.




If you prefer, complete the editable form below, print, and fax to our office.
 


Contact Information

Thank you for providing contact information. It is for EINC use only, it will not be sold or given to any other organization.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Comments: