Medical Records Release Form

Online New Patient Forms

Important Information

Please fill all forms out as thoroughly as possible. By initialing or typing your name in the "Signature" and "Initial" text boxes, you are authorizing and giving Susong Dermatology permission to access your personal health information. For assistance with the forms, please contact us at (423) 870-3376.

*By clicking the “Submit” button, you are authorizing Susong Dermatology to access your personal information, and health records. Please visit our Privacy Practices page for more information about what information we collect and how we use it.

New Patient Forms

Need Assistance?

We have provided our patient forms for you to easily fill out online, or to download and fill out prior to your visit. Please use the links to access the most current forms. If you have any questions, or need assistance, please use the button below to contact us. 

If you would like to request a copy of your medical records, please fill out our online form, or download, print, and complete the below Medical Records Release. You can fax this form to (423) 877-2048 or mail this form to:

Susong Dermatology
Attn: Medical Records
2051 Hamill Road, Suite 301
Hixson, TN 37343

Medical Records Release

Please allow 7 business days for us to release your records.

Downloadable PDF Forms