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 East Tennessee Dermatology Group 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 office’s accessibility and convenience for your patients, you’ll watch your patient satisfaction rates rise. Your patients will enjoy the unique combination of personalized care and proven, advanced clinical expertise offered by East Tennessee Dermatology Group.

To refer a patient, please either complete and submit the form below or print, complete and fax the Patient Appointment Request Form to 865.233.7352.

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

Patient’s Name*

Date of Birth - DD/MM/YEAR*

Address*

City*

State*

Zip*

Insurance*

Patient Phone Number (Home or Cell)*

Desired Appointment Day

Desired Appointment Time

Referring Provider Name*

Referring Provider Phone Number*

Provider Email*

Referring Provider Fax Number

Reason for Appointment*