Appointments (Florida Regional Cancer Centers)

We look forward to your visit. Our doctor's schedules are tailored for your convenience. To schedule an appointment, please call us at (352) 746-1100.

Office Hours 8:00 AM to 5:00 PM - Monday through Friday EST

You may request an appointment online by completing the form below. One of our appointment schedulers will respond to your request within 48 hours. Please do not use this form if you have an urgent medical problem or to re-schedule an existing appointment.

If you are a new patient, fill out the new patient form below, which will save you time in the office.

Request An Appointment

First Name:
Last Name:
Address:
Phone Number:
Email:
I am a(n):	New Patient Existing Patient
Select a Doctor
Type of Appointment:	Follow Up New Problem (Describe Problem Below)

Desired Day/Date:	mm/dd/yyyy
Desired Time:

New Patient Registration Form

Title:	Mr. Ms. Dr.
Last Name:
First Name:	M.I.:
Social Security Number:
Driver License #:
Date of Birth ( mm/dd/yyyy):	Age: Sex: Male Female
Parent/Guardian:
Address:
City:
State:	i.e. : FL
Country:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
Place of Employment:
Work Address:
Primary Insurance Carrier's Name:
Secondary Insurance:
Name of Spouse:
Responsible Party:
Primary Care Physician's Name:
Name of Referring Physician:
Emergency Contact:
Relationship:
Emergency Contact Address:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:
Patient Eligibility Waiver: I hereby attest that I have provided current insurance information. I further agree that should it be determined that I am ineligible or services are denied to me under my Health/Insurance Plan, I will be responsible for payment to Florida Regional Cancer Centers (FRCC) for those services disallowed, ineligible, or not covered. I authorize the release of my medical history and documents directly to my insurance company for the purpose of payment for medical services and that payment for medical services be made directly to Florida Regional Cancer Centers (FRCC).
Signature (Type Name): Date: mm/dd/yyyy

Medical History (For New Patients Only)

Patient Name:
Previous Surgeries
Type:	Date:
	mm/dd/yyyy
	mm/dd/yyyy
	mm/dd/yyyy
Do you have the following?
Heart Problems?
Pulmonary Disease?
High Blood Pressure?
Diabetes?
Previous Strokes?
Other (please describe below)

Allergy to Medication?
If yes, please list: (Medication and type of reaction (rash, swelling, etc)

Family History of Cancer?: ("P" for father's or "M" for Mother's side)
Type of Cancer: (i.e.: lung cancer)	Relationship: (i.e: Uncle)	P or M




Smoking and Alcohol History?
Cigarettes: Number of packs per day?	For how many years?
Quit smoking? For how many years?
Other (Select if applicable):
Alcohol Consumption?
Beer?
Wine?
Spirits?
Social History:
Place of Birth:
Occupation:
# of Children:	# of Siblings:
Health of your Spouse:
Hobbies:
Current Medications:
Diet:
Red Meat
White Meat
Eggs
Vegetables
Fruits
Butter and Cheese
Desserts
Grains and Cereal
Coffee (cups per week)
Tea (cups per week)
Milk (cups per week)
Soft Drinks (cans per week)