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Physician Referral

Does your patient need a dermatologist? WE’VE GOT YOUR BACK. And your patient’s back, front, arms, legs, neck, head and feet.

Refer to Dermatology Associates of Knoxville and you’ll never look back. In fact, you’ll look forward to discussing your patients and their cases directly with our board-certified dermatologists. By taking advantage of our practice’s accessibility and convenience for your patients, you’ll watch your patient satisfaction rates rise and your patients will enjoy the unique combination of personalized care and proven, advanced clinical expertise offered by Dermatology Associates of Knoxville.

To refer a patient, please either complete and submit the form below or print, complete and fax the Patient Appointment Request Form to 865.205.5598.

Our Offices:
Knoxville, UT Medical Center
Knoxville, Dowell Springs
Knoxville, Farragut Medical Building
Powell, Tennova North

Please be sure to submit or fax a unique form for each individual patient you are referring.

    Patient’s Name*

    Date of Birth - MM/DD/YEAR*

    Address*

    City*

    State*

    Zip*

    Insurance*

    Language Translator Needed (Please Specify):

    Patient Phone Number (Home or Cell)*

    Desired Appointment Day

    Desired Appointment Time

    Desired Appointment Location*

    Referring Provider Name*

    Referring Provider Phone Number*

    Provider Email*

    Referring Provider Fax Number*

    Reason for Appointment*

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