Appointment Requests Form

Welcome to Tampa Bay Hearing and Balance Center, a division of ENT & Allergy Associates of Florida. We invite you to use this form to request an appointment. Fields marked with a red * are required. Please complete as much of the form as possible. This form does not save to your computer so it will need to be completed in one session. Your online request will be responded to Monday – Friday during business hours, 8 AM to 4:30 PM. You may alternatively call us at (813) 315-4327 during business hours.

Appointment Request Details

 

Patient and Contact Information

 

Patient Address

 

Patient Insurance Information

 

Secondary Insurance Information

 

Physician Relationships (Coordination of Care)

  • A visit with our tertiary care physicians usually means you have seen at least one other professional regarding your reason for appointment. Please fill out the next sections to the best of your ability. Input N/A or not applicable if you cannot answer the required information.
  • Referring Physician

  • Primary Care Physician

  • Additional Appointment Reason Associated Specialists

  • Examples may be a Neurologist, Cardiologist, Audiologist who is also involved with your reason for appointment.
 

Disclaimer Statement for Appointment Request or Referral

  • Thank you for using the online form to request an appointment or refer a patient to Tampa Bay Hearing and Balance Center a division of ENT & Allergy Associates of Florida. The Tampa Bay Hearing and Balance Center has provided this form to allow you to begin the new patient registration process from the comfort of your home or office. The information that you submit will be transmitted securely over the Internet. Use of this web site is subject to our Terms Of Use: www.tampabayhearing.com/disclaimer By clicking "Submit": You assert that you and/or your office has obtained the necessary signed release form(s) from your patient to submit/refer them to Tampa Bay Hearing and Balance Center. Our scheduling specialists will contact your patient to obtain additional information and to schedule an appointment. A patient relationship cannot be established until the patient is seen, in person, at Tampa Bay Hearing and Balance Center by Tampa Bay Hearing and Balance Center's medical staff. You agree to the terms of this Disclaimer. If you do not agree to the terms of this Disclaimer, you may call Tampa Bay Hearing and Balance Center at (813) 315-4327 to begin the appointment registration / referral process. We look forward to seeing you or your patient at the Tampa Bay Hearing and Balance Center. Thank you for your referral. Please click SUBMIT once and allow a few seconds for the form to be sent. You will be taken to a confirmation page with further instruction once the form has been submitted.
 

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