Clinic Appointment Request

Thank you for using our online appointment request service. By taking a few minutes to complete this form, you can request an appointment with a Florida Orthopaedic Institute specialist. To expedite your request, please provide as much information below as you can. Because we value your privacy, your personal information will not be used by us other than to schedule an appointment.

We will contact you within 24-hours to assist you with your appointment request. If you submit your request on a holiday or Friday afternoon through Sunday, we will respond by the end of the next business day. If you do not hear from us within this timeframe, have questions, or prefer to make an appointment by phone, please call Florida Orthopaedic Institute at (813) 978-9797 and we will be happy to assist you.

* Denotes required fields.

If your medical problem is an emergency, please go to an emergency room.
Patient Information


* Salutation:
Dr.   Mr.   Mrs.   Ms.   Miss  
* Patient First Name:
    Patient Last Name:
Please enter your legal name as listed on your Driver's License or Birth Certificate.
* Date of Birth:
   
If patient is a minor,
enter a contact name?
 
* E-mail:
 
* Preferred Contact Phone:
(-      Ext.
Alternate Phone:
(-      Ext.
* Best Time To Call Back:


No Preference   or   

 
* Patient Status:
Existing Patient      New Patient

Appointment Information


* Health Insurance:
 
 
* Location Preference:
* Appointment Date Preference:
First Available   or   
* Appointment Time Preference:


No Preference   or   

* Is your injury Work-Related?
Yes     No
* Is your injury related to an Auto Accident?
Yes     No
If Yes, what is the name of the Auto Insurance?


* Did you visit an Emergency Room for this injury?
Yes     No
If Yes, please select the name of the hospital.
If you selected Other, please enter the name of the Hospital.


How did you find out about our Web Appointment Request?