Consultation Request Form

Non-Urgent Consultation Request

Tennessee Retina will contact your patient within 2 business days for appointment scheduling. If there is an urgent appointment need, please contact our office at (615) 983-6000.

Please fax any clinical notes or medication lists to (615) 983-6010.

* Required Fields

*Requesting Physician:
*Requesting Physician Phone:
Requesting Physician Fax:
Tennessee Retina Physician:
*Patient Name:
*Patient Phone:
Patient Alternate Phone:
*Patient Birthdate:
*Diagnosis or Reason for Consultation:
Additional Comments:
If you have a preference of location or time frame needed for the appointment, please include them in the comments area.
*Authentication:
*10 + 7 =	Enter the correct answer to the math question.
Please click the Send button only once.

Consultation Request Form

"Dr. Recchia was super! He greeted me (the mom) when he entered the room and then, greeted my 13 year old daughter. He asked her to pronounce her name for him and then he called her by name during the exam. He was able to get to her to Smile and laugh during a scary and intimidating process. We would definitely go back if needed."

Mary
via Facebook

Consultation Request Form

Non-Urgent Consultation Request

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