UCLA Health Interpreter Request - UCLA Health

Fill out this form to schedule an interpreter and please provide as much lead-time as possible. Please provide at least 72-hours of advanced notice (not including weekends) for language service requests.

NOTE: If you need an interpreter for a Zoom meeting or a MyChart Video Visit for a language other than Spanish or American Sign Language, or for Spanish after business hours, please do not fill out this form; instead, follow the instructions here.

Requester's First Name *

Requester's Last Name *

Requester's Email *

Requester's Phone Number/Extension *

Specific Location *

Department Name *

Street Address *

City *

State or Province *

Zip or Postal Code *

Transplant or Research? *

Yes

Service Recipient's First Name *

Patient will be onsite

Service Recipient's Last Name *

Service Recipient's Date of Birth *

MM/DD/YY or MM/DD/YYYY

Language *

Date of Appointment *

Time of Appointment *

Appointment Duration *

MRN # *

Type of Appointment *

5-Digit Department Code *

Urgent/critical requests for an interpreter please call x78001 and select option 2 to connect with an over-the-phone interpreter (OPI)

Additional Information

For Example: Nature of appointment, facility number, etc.

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