Physician Referral

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Referring Patients to Charlotte Skin & Laser

If you’re interested in referring a patient, please complete the form below or download our referral form and fax it to (704) 333-9757.

First Name

Last Name

Stage Name of

Phone Number

Procedure of Interest

Decision Stage

Message

SMS Opt In

* By checking this box, I consent to receive SMS messages from Charlotte Skin and Laser related to my care, appointments, and services at the phone number provided above. Message frequency may vary. Standard message and data rates may apply. For assistance, reply HELP. Reply STOP to opt out at any time. Please review our Privacy Policy and Terms Of Service.

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