New Patient Registration Forms

We strive to provide our patients with quality care in a timely manner. To help minimize your time in our office, you may securely submit your patient registration forms online prior to your visit. Please allow 1 full business day for forms submitted online to process.

Submit Forms Online

Prefer to Print?
Please present these forms along with your insurance card and photo ID to our front desk when you arrive for your appointment.

Printable Forms


Financial Assistance

Your retina care is important, and we have many options to help ease the burden of financial hardship. Please contact one of our financial counselors to review your options.

If you are uninsured or have high out-of-pocket deductibles, you may qualify for financial assistance based on your income. Read our Financial Assistance Policy below.

Financial Assistance Policy Financial Assistance Policy Spanish


If you think you may qualify, please complete our Financial Application below.

Financial Application Financial Application Spanish

We will review your income vs. expenses to see if you qualify for assistance.  Please be sure to include ALL the required proof of income and expense documents listed on the last page of the application.  

Please submit the completed application by bringing it with you to your appointment, or you may fax or mail the completed form to  

Attn: Billing Dept
Tennessee Retina
345 23rd Avenue N., Ste. 350
Nashville, TN  37203
FAX (615) 320-1213 

 If you have any questions regarding the application, please feel free to contact our office at (615) 983-6000.


Medical Records Request

If you would like to request for us to send or receive your medical records, please print and fill out the Medical Records Release Form below.  

Medical Records Release Form

Requests may be submitted in person or may be mailed or faxed to the Tennessee Retina Main location at

Tennessee Retina
Centennial Professional Plaza
345 23rd Avenue N, #350
Nashville, TN  37203
FAX (615) 510-8237

"Dr. Wallace and the staff are fantastic! The best personal care I've ever had."

via Facebook