| Moffitt

COVID-19 Update: See new visitor policy effective Jan. 3. Learn More

Moffitt Cancer Center is committed to the health and safety of our patients and their families. For more information on how we’re protecting our new and existing patients, visit our COVID-19 Info Hub

Healthcare Professional Referral Form

Complete this referral form for a Moffitt representative to contact your patient within 2 business days or call 1-888-663-3488 .You may locate your liaison or email the liaison team.
The Patient Appointment Center is open Monday-Friday, 7am-6pm and Saturday 8-12 pm

Patient Information:

* Do they have secondary insurance?
Yes No

If you are in Florida, would you prefer your visit to be Virtual or In Person?
Virtual In Person

Healthcare Professional Information:

* Does your office participate with Moffitt's Strategic Alliances Navigation?
Yes No

You may upload a copy of your insurance card (front and back) to help ease the appointment process (DOC/PDF/IMAGES/TXT files accepted)

Once submitted, a scheduler from our patient appointment team will contact you within 2 business days.

Healthcare Professional Referral Form

Since you are referring an established Moffitt patient, please call us directly to schedule your appointment at your convenience at 1-888-MOFFITT 1(888) 663-3488.