Radiology Clinic Consultation Appointment Request

Thank you for your interest in making a clinic consultation appointment with one of our Radiologists. Please provide the requested information below and we will respond to your request as soon as possible. If you need to speak with someone urgently, or if you prefer to discuss the reason for your appointment over the telephone, please call us at (310) 481-7545, M-F 8am to 5pm.

Please do not use this form to request diagnostic imaging study appointments (CT/Mammo/MRI/PETCT/US/XR). X-Rays are walk in and do not require an appointment. Most Screening Mammograms can be scheduled online via MyUCLAHealth at https://my.uclahealth.org/. See our locations at https://schedule.radiology.ucla.edu/map/. To schedule your diagnostic imaging study, please call the Radiology Central Scheduling Team at (310) 301-6800, M-F 7am to 7pm.

Type of request
Clinic Consultation with a provider
Screening Mammogram
Diagnostic Imaging Study (CT/Mammo/MRI/PETCT/US/XR)

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

UCLA MRN (if known)

Email Address *

Phone Number *

Best Time to Call You *

Address

City

State or Province

Zip or Postal Code *

Are you new to UCLA Radiology *

Yes

Referring Doctor *

Do you have a specific IR doctor in mind?

Reason for Appointment?

1st Choice Appointment Date *

MM/DD/YYYY

Primary Preferred Location *

2nd Choice Appointment Date *

MM/DD/YYYY

Secondary Preferred Location: *

Type of Insurance *

HMO

PPO

POS

Self Pay

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