Appointment Request Form

Appointment Request Form
If you're experiencing a medical emergency, dial 9-1-1.

Complete all fields of the form below if you would like an appointment. As a result of the American Recovery and Reinvestment Act, the USF Student Health Services is required to collect patient data regarding race, ethnicity, and language as part of the information provided to the Centers for Medicare & Medicaid Services (CMS). This information is required for all patients.

Please note: you have not been scheduled until you receive an email confirming the date and time of your appointment.
Full Name*

First Name Last Name
Student U# or Employee ID#*
Birth Date*

Month Day Year
Gender*

FemaleMaleTMTFGender Non-Conforming
Marital Status*
Race*
Ethnicity*
Preferred Language*
Email Address*

Confirmation Email
Phone Number*

Area Code Phone Number
Please indicate if you live on campus (residential student) or live off campus (commuting student, USF employee or relative)?*

I am a Residential StudentI am a commuting studentI am a USF EmployeeI am a family member of one of the above
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reason for appointment*

COVID TestingTested Positive for COVID in the last 24hrsCOVID Vaccine Booster (Wed only on Tampa Campus from 1/18/23-3/8/23)Flu Vaccine (walk-in basis only on Tampa Campus, M-F 9-11am/2-4pm)Other (i.e. Urgent Care, Sexual Health, Athletic Trainer, etc.)
Preferred location for your appointment*
Are you symptomatic (experiencing symptoms)?*

YesNo
Please list your symptoms.*
Reason for the appointment (your primary complaint)*
Do you have insurance?*

YesNo
Upload Insurance Card (front/back)

Browse Files

Cancelof
Insurance Company Name
Insurance Company Claims Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Insurance Company Phone Number
Member ID/Policy #
Member Group ID #
Insurance Type
Insurance Policy Holder’s Name

First Name Last Name
Relationship to Policy Holder’s
Policy Holder Date of Birth

Month Day Year
Insurance Policy Holder’s Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Insurance Policy Holder’s Phone Number*
Have you been to the clinic before?*

Yes, I am an existing patient.No, I am a new patient.
Preferred appointment day*

MondayTuesdayWednesdayThursdayFridayFirst available, any day
Preferred appointment time*

Morning (8am to 12pm)Afternoon (12pm to 5pm)First available, any time
Preferred appointment time at Campus Rec (Click all that apply)

12pm to 1pm1pm to 2pm2pm to 3pm3pm to 4pm4pm to 5pm (not available until after 9/12/22)
Preferred appointment time for vaccination (Click all that apply)

Wednesday, 1pm to 2pmWednesday, 2pm to 3pmWednesday, 3pm to 4pm
Preferred appointment time for Flu vaccine (Click all that apply)

Tuesday, 1pm to 2pmTuesday, 2pm to 3pmTuesday, 3pm to 4pmFriday, 1pm to 2pmFriday, 2pm to 3pmFriday, 3pm to 4pm
Will this visit be related to an injury?*

YesNo
If yes, were you at work when the injury occurred?*

YesNo
Select Preferred Method to Notify You of Upcoming Appointment (if you currently subscribe to My Chart patient portal, you will receive appointment reminder through this method)*

Cell PhoneHome PhoneEmailText MessageDo Not Call MeNo Response
Please enter the phone number or email from selected option above.*
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