Immunization Compliance Appointment Request Form

Immunization Compliance Appointment Request Form
Please fill out this form to request an appointment for Immunization Compliance purposes.

Complete all fields of the form below and allow 1-2 business days for our representatives to process your request. Please note: you have not been scheduled until you receive an email confirming the date and time of your appointment.

As a result of the American Recovery and Reinvestment Act, the USF Student Health & Wellness Center 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.

If you're experiencing a medical emergency, dail 9-1-1.
Full Name*

First NameLast Name
Student U# *
Birth Date*

MonthDayYear
Gender*

FemaleMale
Marital Status*
Race*
Ethnicity*
Preferred Language*
Email Address*

Confirmation Email
Phone Number (example listed is SHWC phone #)*

Country CodeArea CodePhone Number
Address (example listed is SHWC Address and can be used in lieu of foreign address-Please retype/select country from drop down)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reason for appointment*

1st MMR2nd MMRMMR TiterTB screening (QFT blood test)Other
Other reason for the appointment *
If the appointment is for a College and/or program, please choose one
Other College and/or program:
Insurance information is required if you do not wish to be self-pay.
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

CityState / Province

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

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

MonthDayYear
Insurance Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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.
Are you currently in the state of Florida?*

YesNo
Please select your arrival date to the USF campus you are attending so that we can schedule your appointment for after your arrival.

MonthDayYear
Date
Preferred Location*

TampaSt PeteSarasota/Manatee
Preferred appointment day (that does not conflict with orientation/classes)*

MondayTuesdayWednesdayThursdayFridayFirst available, any day
Preferred appointment time (that does not conflict with orientation/classes)*

Morning (8am to 12pm)Afternoon (12pm to 4pm)First available, any time
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.*
Should be Empty: