COVID-19 Vaccine Information

IDATB is working with the Florida Health Department to offer COVID-19 Vaccines to eligible patients. Please note that vaccines are given on a scheduled only basis.

Please do not call the office for an appointment.

Fill out the required form below to submit your request for a COVID-19 Vaccine appointment:

Please fill out the electronic form below and submit. After you submit, your form will be reviewed, if you meet the Health Department’s requirements to receive the vaccine, an IDATB employee will reach out to schedule a day and time for you to come and receive the Vaccine.

Additionally, please bring a copy of your driver’s license and a copy of our insurance card (front and back).

    Are you an active patient of IDATB?*

    YesNo

    What is the name of your IDATB Provider?*

    Are you a healthcare worker?*

    YesNo

    What is your title and the name of the healthcare company you work at?*

    Do you have a immunosuppressed diagnosis?*

    YesNo

    What is your diagnosis?*

    Do you currently have insurance?*
    Our Patients will not receive a bill for the COVID-19 Vaccination.

    YesNo

    Will you be available to receive the second vaccine in 3 weeks?*

    YesNo

    Last Name:*

    First Name:*

    Middle Initial:*

    Date of Birth:*

    Mobile Phone Number (Parent or Guardian):*

    Email Address:*

    Address:*

    Apt/Room #:

    City:*

    State:*

    Zip:*

    Sex (Gender assigned at birth):*

    MaleFemale

    Primary Insurance Information:
    If your insurance does not require one of the fields given below, please enter NA into that field.

    Primary Insurance Carrier ID #:*

    Primary Insurance Carrier Group #:*

    Insurance Company:*

    Insurance Company Phone #:

    Insured's Name:*

    Relationship:*

    Insured's Date of Birth:*

    Secondary Insurance Information:
    If your insurance does not require one of the fields given below, please enter NA into that field.

    Secondary Insurance Carrier ID #:

    Secondary Insurance Carrier Group #:

    Insurance Company:

    Insurance Company Phone #:

    Insured's Name:

    Relationship:

    Insured's Date of Birth:

    Is this the patient's first or second dose of the COVID-19 vaccination?*

    FirstSecond

    COVID-19 Testing Site Information

    Our affiliation with the Florida Physicians Alliance (FPA) now allows for IDATB patients to be referred for drive-up COVID-19 testing, with an estimated results turnaround time of 24 hours.

    If you would like to be tested, please call our office at 813-251-8444. Patients must be scheduled by our office to be tested.

    Testing Days: Tuesdays and Thursdays

    Times:   6:30 – 8:30 a.m.

                      5:30 – 7:30 p.m.

    Location:  602 S. Audubon Avenue, Tampa, FL 33609