Referrals and Orders

• Adult Patient Information Sheet
• Affidavit for Adults (Spanish Form #31649, Rev 1/17)
• Authorization for Release of Information (Form #30399, Rev 6/18)
• In Loco Parentis Consent to Treat (Form #31646, Rev 6/20)
• In Loco Parentis Affidavit (Form #32188, Rev 6/20)
• Parent/Guardian Consent for Treatment (Form #31647, Rev 5/20)

• Adult Patient Consent for Treatment
  • English (Form #31648, Rev 12/20)
  • Spanish (Form #31666, Rev 1/17)
• Patient Information for Regional Practices:
  • English (Form #31654, Rev 1/23)
  • Spanish (Form #31655, Rev 4/20)
• Privacy Notice:
  • English (Form #31644, Rev 1/20)
  • Spanish (Form #31645, Rev 1/20)
• What Are My Patient Benefits:
  • English (Form #31735, Rev 8/20)
  • Spanish (Form #32855, Rev 9/20)
    
• Vaccine Policy for Practices:
  • English (Form #32257, Rev 9/20)
  • Spanish (Form #32856, Rev 9/20)
    
    
  • Additional Measles Vaccine Consent Form (Form #34639, Rev 4/25)

• Outpatient Lab Orders (Form #31825, Rev 03/23)

• Call to make a referral: 865-522-0420
• Pediatric Cardiology Referral Request Form (Form #33621, Rev. 10/24)
• Website: East Tennessee Children's Hospital Pediatric Cardiology
• Location: South Tower, 2nd Floor
• Directions and Parking
  

• Cardio Pulmonology Service (Form #31938, Rev 5/25)
  
• Cardiac and Pulmonary Stress Testing - ENGLISH (Form #33115, Rev. 10/21)
• Cardiac and Pulmonary Stress Testing - SPANISH (Form #33117, Rev. 10/21)
  
  
• Echo Lab: Call (865) 522-0420 to schedule / Fax (865) 246-7564
  Patients will register in South Tower, 2nd Floor, Cardiology Office.

• Call to make a referral: (865) 675-8181
• Home Health Intake Data Form (Form #31046, Rev. 1-15)

• Abatacept (Orencia) Infusion (ADM 5245, Rev 8/21)
• Albumin Infusion (ADM 5220, Rev 8/21)
• Alglucosidase Alfa (Lumizyme) Infusion (ADM 5280, Rev 2/22)
• Belimumab (Benlysta) Infusion (ADM 5225, Rev 8/21)
• Cerezyme Infusion (ADM5295, Rev 11/22)
• Cyclophosphamide Infusion (ADM5305. Rev 4/22)
  
• Fabrazyme Infusion (ADM 5300, Rev 11/22)
• Gammagard Infusion (ADM 5230, Rev 8/21)
• Gammunex-C Infusion (ADM 5235, Rev 8/21)
• General (Misc) Infusion (ADM 5260, Rev 8/21)
• Golimumab (Simponi Aria) Infusion (ADM 5250, Rev 8/21)
• Idursulfase (Elaprase) Infusion (ADM 5310, Rev 3/23)
• Infliximab (Remicade) Infusion (ADM 5240, Rev 8/21)
• Iron Sucrose Infusion (ADM 5315, Rev 3/24)
• Laronidase (Aldurazyme) Infusion (ADM 5275, Rev 8/21)
• Methylprednisolone (Solu-Medrol) Infusion (ADM 5255, Rev 8/21)
• NS & Heparin Flush Protocol Orders (Hep01, Rev 12/18)
• Pamidronate Infusion (ADM5290, Rev 11/22)
• Pentamidine Infusion (ADM5285, Rev 2/22)
• Rituximab (First Infusion) (ADM 5200, Rev 8/21)
• Rituximab (Subsequent Infusions) (ADM 5205 , Rev 8/21)
• Tocilizumab (Actemra) Infusion (ADM 5215, Rev 8/21)

• To make a request for a referral, please complete Pediatric Nephrology and Hypertension Request for Consultation (Form #33265, Rev 10/21)
• Website: East Tennessee Children's Hospital Pediatric Nephrology
• Location: Medical Office Building (MOB), Suite 310
• Directions and Parking
• Phone Number: 865-546-3111

Neurology Practice

• Pediatric Neurology Patient Consultation Request Form (Form #33434, Rev 8/24)
• Website: East Tennessee Children's Hospital Pediatric Neurology
• Location: Medical Office Building (MOB), Suite 210
• Directions and Parking
• Practice Phone Number: 865-523-5437

Neurodiagnostics: (865) 523-5437

• Neurodiagnostics Service Form (Form #34703, Rev 6/25)
• Prep for EEG (English Form #30608 Rev 3/25, Spanish Form #31064 Rev 5/25)

• Outpatient Nutrition Order (Form #31770, Rev 4/25)
• For oral aversion/feeding therapy, please see Rehabilitation/Motivating Mealtimes (Form #32353, Rev. 12/22)
• For weight management, see Healthy Ways Clinic
• Phone number: (865) 541-8755

• Complete the Pediatric Plastic and Reconstructive Surgery Referral Request Form (Form #33659, Rev 12/24)
  
  
• Website: East Tennessee Children's Hospital Pediatric Plastic and Reconstructive Surgery
• Location: Medical Office Building (MOB), Suite 510
• Directions and Parking
• Practice phone number: 865-824-4939

• Complete the Physiatry Referral Request Form (Form #31841. Rev 3/25)
• Physical Medicine and Physiatry: https://www.etch.com/medical-services/physical-medicine-and-physiatry/

• Call to make a referral: 865-343-6976
• Website: East Tennessee Children's Hospital Pediatric Psychology
• Location:
  • Koppel Plaza, Suite 410
    2100 Clinch Ave
    Knoxville TN 37916
• Directions and Parking

• Forms:
  
  • Please complete the Referral Request Form linked below with the following documents 1) Last visit 2) Demographics 3) Insurance Card 4) Imaging reports and fax to 865-246-7560.
    Pediatric Pulmonology Respiratory Care Referral Request Form (Form #32259, Rev. 5/24)
    
    
  • Bronchial Provocation Challenge Test - ENGLISH (Form #33114, Rev. 6/21)
  • Bronchial Provocation Challenge Test - SPANISH (Form #33118, Rev. 6/21)
  • What is a Pulmonary Function Test (PFT)?
  • Cystic Fibrosis Sweat Chloride Test (Form #32239, Rev. 9/18)
  • Cardio Pulmonology Service (Form #31938, Rev 5/25)

If you have any questions, please call 865-637-8481.

• Websites:
  • https://www.etch.com/medical-services/lung-respiratory-care/
  • East Tennessee Children's Hospital Pediatric Pulmonology

Fluoroscopy, Ultrasound, Nuclear Medicine, CT: Call (865) 541-8107 to schedule

• Nuclear Medicine Call Memo (Rev. 9/22)
• Nuclear Medicine Gastric Policy Memo (Rev. 9/24)
• Naso-Gastric Tube Placement Memo (Rev. 3/23)

MRI - Fax order form to (865) 541-8287 or email directly to sedation@etch.com to schedule:

• RADIOLOGY AFTER HOURS ONLINE ORDER FORM
  
  
• Outpatient Center Radiology Order Form (Form #32891, Rev 11/25)

• MRI Physician Order Form (Form #30403, Rev 2/24)
• MRI Scheduling (Form #32315)

X-Rays

• Outpatient Center Radiology Order Form (Form #32891, Rev 11/25)

• Rehabilitation Physician Referral Form (Form #32434, Rev 3/25)
• Motivating Mealtimes Referral Form (Form #32467, Rev 09/25)
• Visit their website: https://www.etch.com/medical-services/rehabilitation/

• Procedures with Sedation (Fillable) (Form #33918, Rev 02/25)

• Call to make a referral: 865-769-7900
• Location: 1025 Childrens Way, Knoxville, TN 37922
  
  
• Request for Sleep Consultation (Form #30166, Rev 08/24)
• Sleep Medicine Center Brochure (Form #31742, Rev 05/23)

Surgery (Department)

• Link to your page https://www.etch.com/medical-services/perioperative-surgery/
• Surgery Scheduling – (865) 541-8128/541-8588 (OR)
• Surgery Booking Order (Form #31504, Rev 9/20)

East TN Children’s Hospital Pediatric Surgery (practice)

• East Tennessee Children's Hospital Pediatric Surgery Referral Request (Form #32869, Rev 4/21)
• Website: East Tennessee Children's Hospital Pediatric Surgery
• Location: Medical Office Building (MOB), Suite 510
• Outpatient Wound Consults: (865) 546-2131
• Directions and Parking
• Practice phone number: (865) 546-2131

• The Transfer Center makes the process of pediatric patient transfers easy and seamless: (865) 541-8999

• To make a request for a referral for ETCH Urology or the BRAVE Clinic, please complete Referral Form
• Location: Medical Office Building (MOB), Suite 310
• Directions and Parking
  
• Phone Number: 865-673-9315
  
  
• East Tennessee Children's Hospital Pediatric Urology
• University Pediatric Urology

• For outpatient wound consults, please call Pediatric Surgery at 865-546-2131.