Family Health Center Appointment Request - UCLA Health

Thank you for your interest in making an appointment with one of our Family Health Center physicians. Please provide the requested information below and we will respond to your request as soon as possible. If you need to speak with someone immediately, or if you prefer to discuss the reason for your appointment over the telephone, please call us during regular business hours at (310) 319-4700.

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.

Are you a new patient? *

Yes

First Name *

Last Name *

Date of Birth *

MM/DD/YYYY

Gender *

Email Address *

Address 1

City

State or Province

Zip or Postal Code

Type of Insurance *

Phone Number *

e.g (123-456-7890)

Alternative Phone Number

Best Time to contact you *

Your Primary Care Provider or Specialist

Please select the doctor's name listed on your insurance card or the doctor you have selected as your primary care provider or specialist.

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

All same day appointments are available no earlier than 9:45 A.M. In addition, please call UFHC to verify appointment time.

1st Choice Appointment Date *

MM/DD/YYYY

Time *

2nd Choice Appointment Date

MM/DD/YYYY

Time

3rd Choice Appointment Date

MM/DD/YYYY

Time

We will make every effort to schedule you with the health care provider that you have selected. If your primary care specialist is not available then we will schedule you with another primary care specialist on their patient care team.

If you are seeing one of our subspecialists: Drs. Heinzerling, Murphy, Wallenstein, Wong or Ms. Woo and they are unavailable on the dates that you have selected, our appointment center will contact you with their next available appointment.

I have read and understood the above and agree to use this website to schedule a non-emergent, non-urgent appointment only.

I Understand *

I agree to receive communications from UCLA Health.