• Provider Consult Referral Request

    Pediatric Ophthalmology & Adult Strabismus

  • Please be prepared with the following prior to beginning form:

     
    1. Relevant exam notes from referring provider (upload file)

    2. Patient demographic information (type or upload file)

    3. Patient insurance information (type or upload file)

    4. Guarantor information (type or upload file)


    For URGENT requests, please call 865.262.8473, option 0, in addition to completing this form.

     

    If you prefer to manually fax our old fillable .PDF referral form, it is available here: Old .PDF Referral Form

     

  • Referring Office / Provider

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Knoxville Pediatric Associates

    phone

    fax

    address:

  • Appointment Timing*
  • Reason For Referral*
  • 0/1000

  • Patient Information

  • How do you want to enter Patient Demographic Information?*
  • How do you want to enter Patient Insurance Information?*

  • ** It is OK to upload all patient information as one single multipage document.  Use any of the below upload boxes **

  • Date of Birth*
     / /
  • Patient Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Appointment Preference
  • Appointment Preference

  • Responsible Party

  • Copy Forward Patient Information*
  • Date of Birth*
     / /
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Insurance

  • Patient Relationship to Subscriber*
  • Format: (000) 000-0000.
  • Subscriber Gender
  • Subscriber Date of Birth*
     / /

  • Secondary Insurance

  • Patient Relationship to Subscriber
  • Format: (000) 000-0000.
  • Subscriber Gender
  • Suscriber Dated of Birth
     / /

  • Review & Submit

  • Date
     - -
  • Should be Empty: