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.

SHWC in Tampa 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 (SAME PARKING LOT OF THE YUENGLING CENTER/CAMPUS REC).

We are closed on weekends and USF Observed holidays (see below)

* Winter Break - December 22nd thru January 2nd, 2026
Full Name*

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

Confirmation Email
Cell/Mobile #*
Referred by:*
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*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have insurance*

YesNo
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
Thank you for your submission, someone will call you within 24 hours to schedule you with one of our Athletic Trainers
Date

MonthDayYear
Date
Appointment Time AT Referred you to:

:HourMinutesAM/PM Option
Should be Empty:

ATHLETIC TRAINER REFERRAL FORM