Moffitt
 
 

Patient Registration Form


We invite you to use this secure online form to request a new patient appointment. Your online request will be responded to within the same business day (Monday-Friday 7 a.m. to 7 p.m. and most holidays). Required information is marked with (*). Please fax your medical records to 813-449-8210.

Appointments may also be requested by calling our New Patient Appointment Center at 813-745-3980 (Toll Free at 1-888-860-2778) option #1 anytime between 7 a.m. and 7 p.m. and most holidays. To schedule a Screening and Prevention appointment, contact Moffitt Cancer Center Screening and Prevention at 813-745-6769.

If you are a Breast or Gyn patient, please click here.

Note: (*) required fields are needed before an appointment can be set.

Patient Information

Patient’s First Name:*
 
Patient’s Last Name:*
 
Patient’s Gender:*
Patient’s Phone:*
 
Patient's Alternate Phone:*
 
Patient’s Birthdate:* (mm-dd-yyyy)
 
Patient’s SSN#:
Patient’s Email:*
 
Patient’s Address:*
 

Diagnosis Information

Medical Diagnosis: *
 
Referring Physician's First Name:
Referring Physician's Last Name:
Referring Physician’s Phone:
Do you request a specific physician
by name at Moffitt?
Name of the Moffitt Physician:

Insurance Information

Insured's First Name:
Insured's Last Name:
Insured's SSN#:
Insured's BirthDate:
Insured's Insurance Company:
Insured's Policy #:
Insurance Company Phone:
DISCLAIMER for Patient Pre-Registration

You must read and agree to the following disclaimer before submitting the Pre-Registration Form for Patient Referral.

Thank you for visiting the New Patient Appointment Center Pre-Registration website. The H. Lee Moffitt Cancer Center and Research Institute Hospital, Inc. and the H. Lee Moffitt Cancer Center and Research Institute Screening Center, Inc. (collectively, "Moffitt") have provided this New Patient Appointment Center web page to allow you to begin the new patient registration process from the comfort of your home. The information that you submit will be transmitted securely over the Internet. Use of this web site is subject to our Terms and Conditions of Use and Internet Privacy Policy.

You understand that your use of this New Patient Appointment Center Web page is not a substitute for seeing a doctor or medical professional regarding your medical condition. We will notify you when an appointment is scheduled. Of course, a patient relationship cannot be established until you are seen in person at Moffitt by Moffitt's medical staff.

By clicking "Submit", you agree to the terms of this Disclaimer. If you do not agree to the terms of this Disclaimer, you may call Moffitt at 813-745-3980 or 1-888-860-2778 to begin the registration process. Thank you for pre-registering with our on-line form.



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