Submit a Referral — University Urology

Referring Practice Information

Practice / Organization Name *

Referring Physician *

Practice Phone *

Practice Fax *

Contact Person

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone *

Patient Email

Insurance *

Referral Details

Reason for Referral *

Clinical Notes / Additional Information

Urgency

Emergent

Please call our office at (865) 305-9254. If you cannot reach us, send the patient to the ER.

Urgent / ASAP

As soon as possible — no specific time frame

Semi-Urgent

Within 2–4 weeks

Routine

Standard scheduling — no urgency

Referral Documents

Required documents: Please include the patient's facesheet / demographics and a copy of their insurance card (front and back). Without these we cannot add the patient to our system.

You may also attach referral letters, labs, imaging reports, or clinical notes. Combine multiple documents into a single PDF if possible.

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Drag & drop or click to attach referral documents

PDF, JPG, PNG · Max 20 MB

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🔒 Transmitted via HTTPS encrypted connection. PHI handled in accordance with HIPAA. University Urology, PC — 865-305-9254

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Referral Received

Thank you — the referral has been received by our scheduling team. Our scheduling team will prioritize this referral and coordinate the appointment.

For urgent cases, please also call us directly at (865) 305-9254.

Referral confirmation number:

Please retain this number for your records.

Submit a Patient Referral