Referring Physicians

PENTA accepts most insurance plans and will be happy to assist you with your referrals. We understand how valuable your time is, therefore once we receive your referral form, we will be happy to call your patient and schedule their appointment and inform your office of your patient's appointment date and time. Please complete the following form and await a call from our friendly office staff!

If you have any questions, please contact Beth at 865-673-8229 or email at i nfo@penta-knox.com.

Physician Info

Physician's Name

Physician Phone Number

Physician Fax Number

NPI #

Patient Info

Patient's Name

First Name

Last Name

Date of Birth

Patient's Parent(s) Name

Patient's Phone Number

Alternate Phone Number

Street Address

City

State

Zip

Insurance

Reason for Referral / Special Notes

ID Number

Appointment Urgency

PENTA

PENTA

Referring Physicians

PENTA

Referring Physicians

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