Athletic Trainer Referral Form
Please fill out the following information and hit "Submit" below. We will contact your student to schedule within 24-48 business hours. Please contact us at atcreferral@omgtb.com if you have any questions. INCOMPLETE OR INCORRECT INFORMATION WILL RESULT IN A DELAY IN SCHEDULING YOUR ATHLETE
Athletic Trainer Information:
Name of Referring ATC
*
First Name
Last Name
School Name
*
Athlete Demographics:
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
Guardian Name
*
First Name
Last Name
Guardian Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Insurance Information:
Insurance Provide Name
*
Member ID
*
Subscribers Name
*
First Name
Last Name
Upload Front of Insurance Card
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Choose a file
Cancel
of
Upload Back of Insurance Card
Browse Files
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Choose a file
Cancel
of
Appointment Information
Date of Injury
-
Month
-
Day
Year
Date
Problem to be Evaluated
*
Appointment Location Requested
*
Please Select
Tampa: 4541 S Dale Mabry Hwy, Tampa, FL 33611
St Pete: 2805 54th Ave N, St Petersburg, FL 33714
Brandon: 10740 Palm River Rd Suite 310, Tampa, FL 33619
Fishhawk: 13837 Circa Crossing Dr, Lithia, FL 33547
Sun City: 1901 Haverford Ave Suite 107, Sun City Center, FL 33573
Riverview: 6901 Simmons Loop Suite 201, Riverview, FL 33578
Winter Haven: 100 Ave I NE, Winter Haven, FL 33881
Plant City: 420 North Plant Ave, Plant City, FL 33563
Wesley Chapel: 2553 Windguard Circle, Wesley Chapel, FL 33544
Physician Requested
*
Please Select
Dr. Stuart Goldsmith: General Orthopaedics
Dr. Scott Goldsmith: Joint Replacement & General
Dr. Edward Becker: Sports Medicine & General
Dr. Mark Sando: Sports Medicine & General
Dr. Christopher Donaldson: Shoulder/Elbow & General
Dr. Bryan Butler: Shoulder/Elbow & General
Dr. Adam Jester: Trauma & General
Dr. Thao Nguyen: Hand/Wrist & General
Dr. Patrick Donovan: Foot & Ankle
Dr. Trey Shield: Joint Replacement & General
Dr. Germanuel Landfair: Joint Replacement & General
Dr. Clayton Bauer: Neck & Back
Dr. Nick Sexton: Sports Medicine & General
Dr. Daniel Tarazona Sports Medicine & General
Any Additional Information
Submit
Should be Empty: