SHWC Athletic Trainer Appointment Request Form

ATHLETIC TRAINER REFERRAL FORM

ONLINE APPOINTMENT REQUEST
This form can be completed to request an appointment with the Athletic Trainers (AT) located at Student Health and Wellness Center.

Student Health & Wellness Center will be closed Friday, May 15, 2026

Any forms submitted today, May 14, 2026 after 4pm and throughout the weekend will not be processed utill after we resume operations on Monday, May 18, 2026.

If you're experiencing a life-threatening medical emergency, Dial 9-1-1.

If you or someone you know is experiencing a personal or emotional crisis, please call (813) 974-2831 and press option 3 to speak with a licensed mental healthcare professional 24/7.

For non-emergency medical concerns, please call (813) 974-2331 to connect with our after-hours line.

We will resume operations on Monday, May 18, 2026
Full Name

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

Confirmation Email
Cell/Mobile #
Referred by:
Services Needed:
Services Needed:
Services Needed:
Complete all remaining fields of the form below if you are requesting an 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
Age
Gender
Marital Status
Ethnicity
Race
Preferred Language
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have insurance
Upload Insurance Card

Browse Files

Cancelof
Insurance Company Name
Insurance Company Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Member ID/Policy#
Member Group ID#
Insurance Type
Insurance Policy Holder's Name

First NameLast Name
Insurance Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Policy Holder's Phone Number
Date

MonthDayYear
Date
Appointment Time AT Referred you to:

:HourMinutesAM/PM Option
Thank you for your submission, someone will call you within 24 hours to schedule you with one of our Athletic Trainers
Should be Empty:

ATHLETIC TRAINER REFERRAL FORM