UCLA Head and Neck Surgery New Patient Online Appointment Request Form - UCLA Health

Thank you for your interest in the Department of Head and Neck Surgery at UCLA.

Please fill out the form below and a member of our staff will contact you to schedule an appointment.

You can also call our appointment scheduling number at 310-206-6688 to schedule directly with our appointment specialist during business hours (8 AM – 4:45 PM).

Have you been seen here at UCLA Head and Neck Surgery before? *

Yes

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Email Address *

Zip or Postal Code *

Phone Number *

What medical problem would you like an appointment for?

If chosen Other, please specify:

Have you been referred to a specific physician in our department?

Yes

If Yes, please list physician's name:

Who made the referral? *

Please briefly describe your medical condition and the reason for the visit: *

I agree to receive communications from UCLA Health.