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International Patient Appointment Request

Welcome to International Patient Services

We are here to support you and your family every step of the way. Our International Patient Services Department offers personalized assistance to help coordinate your care and meet your unique needs.

To begin, please complete the appointment request form below. A member of our team will contact you to guide you through the next steps.

If you prefer, you can also reach us directly at 813-745-4685 or by email at international@moffitt.org.

We look forward to assisting you.

Appointment Details

What best describes your first appointment at Moffitt?
Have you had any of the following (select all that may apply):
Would you be interested in learning about clinical trials at Moffitt?
Do you have an insulin pump or glucose monitor?
Have you ever had a Mammogram before?
Have you ever been diagnosed with breast cancer?
Are you currently experiencing any breast problems?
Are you 50 years of age or older?
Have you ever had a Lung Screening CT before?
Do you have a primary care provider?
Are you interested in smoking cessation resources?
How were you referred to Moffitt?

Appointment Preferences

Preferred appointment timeframe (select date range) :
Are you requesting to see a specific Moffitt provider?

Patient Contact Information

Do you have a visa?
Interpreter required?

Emergency Contact Information

Patient Insurance Information

Is the patient the policy holder?
Does the patient have secondary insurance?

Cambiar el idioma

Si no encuentra la información que busca o si desea programar una cita, llámenos gratis al 1-888-663-3488.

Gracias.

 

 

 

 

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