Provider Referral Form

If you a medical provider and would like to refer a patient to Dr. Dumont, please complete the following form and fax the form and relevant medical records to (803) 296-9699.

If you are a patient, do not use this form. Please use our appointment request form or call our team at and leave a message. A member of our team will contact you during business hours to set up an appointment.

  • American Orthopaedic Society for Sports Medicine
  • The Arthroscopy Association of North America
  •  American Academy of Orthopaedic Surgeons
  • International Society for Hip Arthroscopy