SHWC Online Inquiry/Request Form

Online Inquiry/Appointment Request Form

If you're experiencing a life threatening medical emergency, STOP! Dial 9-1-1 and do not complete this form.
Student Health Services is now the Student Health and Wellness Center!

Our new facility is located at: 12530 USF Bull Run Drive, Tampa, FL, 33620 on the purple Bull Runner route. Suggested parking is located in lot 22D off of USF Alumni Drive, between USF Bull Run Drive and USF Genshaft Drive.

For Apple coordinates to our main entrance CLICK HERE. View a Map with driving routes HERE

Please note: As we expand our team, phone service will be limited.

Tampa/Sarasota-Manatee students should complete this form to schedule an appointment or reach clinical personnel. St Pete students can call (727) 873-4422 or complete this form.
Full Name*

First (Given) Last (Family)
Student U# or Employee ID#*
Email Address*

Confirmation Email
Cell/Mobile #*
Please select one*

I need to schedule a medical appointmentI have a general question
Question(s) *
Complete all remaining fields of the form below if you are requesting a medical appointment. As a result of the American Recovery and Reinvestment Act, the USF Student Health and 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.

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

MonthDayYear
Gender*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred location for your appointment*
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

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.
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
Will this visit be related to an injury?*

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

YesNo
Should be Empty:

Online Inquiry/Appointment Request Form