Email Provider - Sweetwater Hospital Association

PATIENT ASSISTANCE REQUEST

Please check or complete the sections that apply to you:

Name(Required)

First Last

Date of Birth:(Required)

Phone(Required)

*All responses will be made by phone call.

Physician's Name(Required)

Reason for Contact (please check one or more):(Required)

Established patient Sick visit needed today- Symptoms/reason:

Established patient Sick visit needed ASAP- Symptoms/reason:

Question about test results - Test(s):

Medication refill:

Referral or paperwork request

*Return calls will not be routinely made. Please check with your pharmacy.

Symptoms/Reason:

Specify Test Name or Type:

Pharmacy Name

Pharmacy Phone

Medication Name

dose/strength

frequency

Medication Name

dose/strength

frequency

Medication Name

frequency

dose/strength

Is this an urgent need?

Describe:

Routine appointments and new patient appointments should be made by calling 865-213-8200 and selecting option 3 for the appointment line.

Details / Comments / Other:

By submitting this electronic Patient Assistance Request, I acknowledge understanding that:

Messages received after hours or on weekends will be reviewed this office’s next business day.
While we strive to return all calls the same day, the timing of a response depends on the nature/urgency of the need.
If further assistance is needed you may contact the Patient Advocate by phone at (865) 213-8670 or via the contact form at www.sweetwaterhospital.org.

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