Dining Refund Form

This form is for reporting dining refund requests.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Date

Approx. Time of Purchase

Start typing to search – please select the location(Required)

Start typing to search – please select the hospital location(Required)

Shands, Springhill, Oaks Mall, Health Science Center, Fixel Institute, etc.

Method of Payment(Required)

Disputed Amount

Type of Credit/Debit(Required)

Last Four Digits Of Credit/Debit(Required)

Please enter the last four digits of your credit/debit card used in this purchase.

UFID(Required)

Please Provide a Description of Your Problem(Required)

Please Attach Your Receipt

Drop files here or

Max. file size: 44 MB.

CAPTCHA

Contact Us