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:
*7 + 2 =	Enter the correct answer to the math question.
Please click the Send button only once.

Consultation Request Form

"Very friendly staff, wife had an issue with her eyes, they helped us feel comfortable and put us at ease, waiting areas were spacious and did not feel cramped with people... we did not wait long to be seen. Staff was knowledgeable and friendly and positive atmosphere."

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Consultation Request Form

Non-Urgent Consultation Request

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