Division of Rheumatology New Patient Referral

Thank you for referring your patient to the UCLA Gonda (Goldschmied) Venous Center. Please enter all required information below. One of our friendly staff will contact you within 24 - 48 hours. You can also call our office at (310) 825-4357.

For patients with HMO coverage to be seen at the venous center, an insurance authorization is required from their primary care referring physician. With a patient's consent, a copy of the consultation note will be forwarded to the referring physician.

Referring Physician Information

Contact Information of Person Completing Form

Patient Information

e.g (123-456-7890)
MM/DD/YYYY


INSTRUCTIONS: Please fax any available medical records to (310) 794-6553 for Westwood office or (310) 582-6352 for Santa Monica office. To facilitate processing, please fax the front and back of patient's insurance card, if available.