WLA Peds Appointment Request - UCLA Health

New patients, or current patients who do not have a myUCLAhealth account, can use this form to request an appointment. Current patients with a myUCLAhealth account, please sign in to my.uclahealth.org to request an appointment.

Thank you for your interest in making a NON-URGENT appointment with one of our West Los Angeles pediatricians. Please provide the requested information below, including two phone numbers where we can reach you, and we will contact you in the next 2-3 business days. If you need an URGENT, SAME-DAY appointment or if you prefer to discuss the reason for your appointment over the telephone, please call the office directly during regular office hours at (310) 231-9150.

Please note that special charges related to your care may apply. Some examples of these special charges for your continued care include, but are not limited to, Missed Appointments, Completion of Forms, and Telephone/Email Consultations. Should you have any questions about these charges, please feel free to contact our clinic directly.

If you are a new patient, please print and fill out the following forms and bring with you to your first appointment:

Office Information
Health History Form
Terms and Conditions (for medical treatment within UCLA)

Please also bring your child's immunization records to the first appointment.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

MM/DD/YYYY

Gender *

Mobile Phone

Home Phone

Best time to call *

Email Address *

Parent or Guardian's First Name

Parent or Guardian's Last Name

Parent or Guardian's Phone Number

Street Address *

City

Country *

State or Province

Zip or Postal Code *

Patient's Preferred Language *

Is an interpreter needed?

Yes

Type of Insurance *

Medical Group (if applicable)

Is this your first time scheduling with a UCLA physician? *

Yes

Which type of appointment is the patient seeking?

What service(s) is the patient seeking care for? Select all that apply:

Brief explanation of the reason for the appointment and/or diagnosis: *

Are you interested in seeing a specific doctor? If yes, please give a name:

I agree to receive communications from UCLA Health.