Online Appointment Request Form | Cleveland Clinic Florida

Patient Information

The person who will be seeing the physician.

Title

First Name

Middle Name

Last Name

Maiden Name

Suffix or Professional Title

Gender

Marital Status

Date of Birth

Ex. (mm/dd/yyyy)

Social Security Number (Last 4 digits)

Country

Address Line 1

25 characters maximum. Use Address Line 2 if more room is needed.

Address Line 2

25 characters maximum.

City

State or Province

ZIP or Postal Code

Primary Phone Type Describe Other

Primary Phone

Ext.

Secondary Phone Type Describe Other

Secondary Phone

Ext.

Email

Retype Email

Appointment Details

Requestor Information

The person completing this form.

I am submitting this appointment request for my

Title

First Name

Last name

Email

Retype Email

Phone

Ext.

Phone Type Home Mobile Work Other

Describe Other

Are you over 18?

Yes No

Would you like to receive health-related mailings from us?

Yes No

Referring Physician Information

Patient Referred by outside Physician?

Yes No

Referring Physician First Name

Referring Physician Last Name

Referring Physician Title:

Medical Group Name

Country

Street Address

City

State or Province

ZIP or Postal Code

Phone

Ext.

Alternate Phone

Ext.

Fax

Is this physician also the patient's Primary Care Provider?

Yes No

Primary Health Insurance Information

All fields are required unless noted as optional.

Does the patient have health insurance?

Yes No

Reason for No Insurance

Person responsible for the patient account

Other

Please provide insurance information as it appears on the insurance card.

Name of Insurance

Effective Date of Medicare (Part B)

Effective Date of Medicare (Part A)

Mail Claims To (Name)

Mail Claims To (Address)

City

State

Zip code

Phone

Ext.

Policy # or ID #

Group #

Electronic Payor ID

Policy Holder Information:

Relationship to Patient

Other Relationship

Name of Subscriber or Policy Holder

Subscriber's Employer Name

Subscriber's Employer Street Address

City

State

Zip Code

Subscriber's Date of Birth

Subscriber's Email

Secondary Health Insurance Information

Does the patient have secondary insurance?

Yes No

Name of Secondary Insurance

Effective Date of Medicare (Part B)

Effective Date of Medicare (Part A)

Mail Claims To (Name)

Mail Claims To (Address)

City

State

Zip code

Phone

Ext.

Policy # or ID #

Group #

Electronic Payor ID

Secondary Subscriber or Policy Holder Information

Policy Holder's Relationship to Patient

Other Relationship

Secondary Insurance Subscriber or Policy Holder Name

Subscriber's Employer Name

Subscriber's Employer Street Address

City

State

Zip Code

Date of Birth

Subscriber's Email