Appointment Requests Form

Tampa Location

Tampa Bay Hearing & Balance Center
5 Tampa General Cir STE 610
Harbourside Medical Tower
Tampa, FL 33606-3659
P: 813.315.4327 F: 813.315.4329
Hours: M-F 8:00 a.m. - 4:30 p.m

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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

Preferred Physician
First AvailableLoren J Bartels MD FACSChristopher J Danner MD FACSKyle P Allen MD MPHMickie J Hamiter MD
Appointment Reason
If you choose other reason please use the next field to briefly state the reason.Chronic Ear InfectionHearing LossConductive Hearing LossEar TumorVertigo or Other DizzinessImbalanceEar Noise or TinnitusOther reason
Additional Appointment Reason Information
When was the patient's most recent hearing test? If the exact date is unknown estimate the 1st of the month and year.

Patient and Contact Information

Patient First Name *
Patient Middle Initial
Patient Last Name *
Patient Suffix
Gender *
MaleFemale
Date of Birth *
Cell Phone *
Email *
Additional Contact Method
Preferred Contact Method
EmailCell PhoneAdditional Contact Method

Patient Address

Address *
City *
State *
Zip Code *

Patient Insurance Information

Insurance Name *If you are not using insurance please input N/A or not applicable in this and the following required fields.
Member ID / Certification Number *
Policy / Group Number *
Policy Expiration Date
Insurance Product Type *
HMOPPOPOSEPOOtherNot Applicable

Secondary Insurance Information

Secondary Insurance Information
Input only if applicable.

Physician Relationships (Coordination of Care)

Instructions 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

Referring First Name *
Referring Last Name *
Referring Phone Number
Referring Fax Number
Referring DirectTrust Address

Primary Care Physician

PCP First Name *
PCP Last Name *
PCP Phone Number
PCP Fax Number
PCP DirectTrust Address

Additional Appointment Reason Associated Specialists

Specialists Examples may be a Neurologist, Cardiologist, Audiologist who is also involved with your reason for appointment.
Input List of Specialists and Contact Information

Disclaimer Statement for Appointment Request or Referral

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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