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:
*0 + 8 =	Enter the correct answer to the math question.
Please click the Send button only once.

"Dr. Wallace is very kind and really knows his stuff! He explained my eye situation in way that was easy to understand. He performed laser procedure and had me in and out very quickly! Highly recommend!!"

via Facebook

Consultation Request Form

Non-Urgent Consultation Request

Clinical Trials

Patient Portal

Learning Center