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Request a New Patient Appointment

No Referral Needed

Please complete this online form to begin the appointment scheduling process. Most insurance plans do not require a referral for an appointment. The information you provide on this form will help us get you to the right team of experts. Our Patient Access Team will contact you as soon as possible. Or, you can call us:

Patient Appointment Center: 1(888) 663-3488
Hours: Monday-Friday, 7 a.m. to 6 p.m. and Saturday, 8 a.m. to noon ET.

What You'll Need

Whether you call us or complete the online form below, you'll need to have a few things ready:

Patient's full name, contact information and date of birth
Reason for visit
Patient's primary insurance information

Appointment Details

What best describes your first appointment at Moffitt?

Discuss a cancer concern, confirmed diagnosis or treatment plan

Seeking a second opinion on a cancer concern or treatment plan

Screening, genetic testing or survivorship exams

Do you have a cancer diagnosis or treatment/surgical plan?

What is the known cancer type or cancer concern?

Please explain the known or suspected cancer type

Would you be interested in learning about clinical trials at Moffitt?

Yes I would

Not at this time

What type of screening or exam are you seeking?

Do you have an insulin pump or glucose monitor?

Yes

No

Have you ever had a Mammogram before?

Yes

No

What was the date of your last Mammogram? If you can't recall the exact date, please enter the Month and Year.

What imaging center has your previous films?

What provider has any previous mammogram films?

Have you ever been diagnosed with breast cancer?

Yes

No

Are you currently experiencing any breast problems?

Yes

No

Please describe the breast problems you are experiencing. A member of our team will contact you to discuss and assess if additional testing might be relevant for you.

Are you 40 years of age or older?

Who should we seek a referral or script from for this appointment?

Which physician should receive your mammogram report?

Are you 50 years of age or older?

Yes

No

Please enter the number of years that you smoked cigarettes

What is the average number of cigarette PACKS smoked per day?

Have you ever had a Lung Screening CT before?

Yes

No

When was your last lung screening performed?

Do you have a primary care provider?

Yes

No

Who is your primary care provider?

Are you interested in smoking cessation resources?

Yes

No

How were you referred to Moffitt?

I am referring myself

I am being referred by my physician

I am being referred by my employer

What is the name of the physician who is referring you?

Appointment Preferences

Do you have a preferred Moffitt location?

First Available

Magnolia Campus, 12902 USF Magnolia Drive, Tampa

McKinley Clinic, 10920 N. McKinley Drive, Tampa

International Plaza, 4101 Jim Walter Blvd., Tampa

Wesley Chapel, 2590 Healing Way, Wesley Chapel

SouthShore, 2709 E. College Ave., Ruskin

Virtual (only available if patient is in Florida)

Mobile Lung Screening (Scheduler will confirm preferred mobile location)

Speros Campus - Opening in Pasco County January 2026

Are you requesting to see a specific Moffitt provider?

Yes

No

Please enter the name of the Moffitt provider you would like to see.

Patient Contact Information

First Name

Last Name

Patient date of birth

Patient street address

Patient city

Patient state

Patient zip code

Email address

Patient Phone Number

Phone Type

Do you give permission for Moffitt to text you about your appointment?

Yes

No

Patient Insurance Information

Primary insurance

What is the name of your primary insurance provider?

Policy ID number

Phone number on the back of your insurance card

Address or PO Box on the back of your insurance card.

Is your primary insurance a Medicare Advantage Plan? (Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare.)

Who is your Primary Care Physician? (Medicare Advantage plans require authorization from your physician before processing; by providing this information, we can get authorization on your behalf.)

Is the patient the policy holder?

Yes

No

Policy Holder's First Name

Policy Holder's Last Name

Policy Holder's Date of Birth

Relationship to the Policy Holder

Patient's Employer

Does the patient have secondary insurance, or a Medicare Supplement (Medigap) Plan?

Yes

No

Secondary insurance plan name

Secondary insurance policy number

Phone number on the back of your secondary insurance card

Address or PO Box on the back of your secondary insurance card

Step 1/ 4

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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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