Referring Physician Form

We invite you to use this secure online form to request a new patient appointment. Your online request will be responded to within one hour during business hours (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 Lifetime Cancer Screening call 813-745-6769.

Note: (*) required fields are needed before an appointment can be set.
Referring Physician Information
* Referring Physician First Name:
* Referring Physician Last Name:
* Referring Physician's Phone:
Name of Moffitt Physician being requested:
* Referring Physician's Office Fax Number :

(Please include your office fax number for future communication)
* Referring Physician Email:
Patient Information
* Patient's First Name:
* Patient's Last Name:
* Patient's Gender:
Patient's SSN#:
* Patient's BirthDate:
Patient's Address:
Patient's City:
Patient's State:
Patient's Zip:
* Patient's Phone:
Patient's Insurance Company Name:
* Alternate Phone:
Diagnosis Information
* Medical Diagnosis :
Are you interested in Screening/ Prevention Services?
Any Questions or Comments:

Full Name of person completing this form

Disclaimer Statement for Physician Referral

Thank you for visiting the New Patient Appointment Center to refer a patient to Moffitt. 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 referral process from the comfort of your home or office. 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 Useand Internet Privacy Policy.

By clicking "Submit"

  • You assert that you and/or your office has obtained the necessary signed release form(s) from your patient to submit/refer them to Moffitt. Our scheduling specialists will contact your patient within one business day to obtain additional information and to schedule an appointment. A patient relationship cannot be established until the patient is seen, in person, at Moffitt by Moffitt's medical staff.
  • 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) 979-3980 or 1-888-860-2778 to begin the referral process.We look forward to seeing your patient at the Moffitt Cancer Center. Thank you for your referral.

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