Online Consult Forms

The following forms are required as part of your online consultation. Please read carefully as we will be unable to process your request if any of the required forms are missing from your submission. Click on the links below to access each document.

Online Consult Checklist
For your convenience, this checklist will guide you in obtaining all the records you need and forms that must be included in your submission package prior to mailing it to us. Having a complete submission will help avoid delays during your online consult process.

Patient Telemedicine Consent Form (Required)
You need to complete and sign this form authorizing your physician to request an opinion on your behalf.

Physician Request for Consultation  (Required)
This form needs to be completed and signed by your physician for he or she to receive our medical opinion. Moffitt Cancer Center's Online Consult is a physician-to-physician service, therefore this form is required.

Authorization for Use or Disclosure (Required)
This form needs to be completed and signed by you. This authorizes us to release copies of any medical reports generated on your behalf to you and your physician.

Terms of Use

Notice of Privacy Practices | Notificación de las prácticas de privacidad (Spanish) (PDF)

Once we receive your submission package, one of our representatives will contact you via email confirming receipt. Next, your physician will be notified within 14 business days confirming completion of the online consult. If you have any questions or concerns, please contact us at 813-745-4685 or internationalreferrals@moffitt.org. Thank you for allowing us to be your online consultation source.