UCLA Health | New Patient Appointment Request

If you are having a medical emergency, call 911 or go to your nearest emergency department. For urgent matters, please contact your doctor's office or find an Immediate Care location near you.

Existing patients can request appointments and communicate with their care team by signing into myUCLAhealth.

Please use this form only if:

You have never been a patient at UCLA Health, or
You have been a patient at UCLA Health but are seeking an appointment with a new doctor or within a new clinical specialty

Note: all physicals, follow ups and medication management appointments should be directed to your current care team.

Important reminder: You could receive both preventive care and follow-up or diagnostic care during the same medical appointment. Although most health insurance plans cover preventive care, you may get a separate charge for other types of care that take place at the same appointment.

After you submit the form, a Physician Referral Representative will call you back within 1-2 business days (excluding weekends/holidays) to make an appointment. You may also speak with a representative directly at 310-825-2631, Monday – Friday, 7 am to 7 pm.

First Name *

Last Name *

Mobile Phone

Home Phone

Best Time to Call

Email Address *

Street Address *

City

Country *

State or Province

Zip or Postal Code *

Date of Birth *

MM/DD/YYYY

Gender *

Is an interpreter needed?

Yes

Patient's Preferred Language *

Type of Insurance *

Medical Group (if applicable)

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

Yes

Which type of appointment are you seeking?

What service(s) are you seeking care for? Select all that apply:

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

If you were referred by a doctor, what is the referring doctor's name?

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

I agree to receive communications from UCLA Health.

UCLA Health Appointment Request