UCLA Health 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.

If you are an existing patient, you can request appointments and communicate with your care team in myUCLAhealth.

Only use this form if:

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

First Name *

Last Name *

Email *

Country*

Street Address

City

State*

Zip Code*

Mobile Phone*

Country Code

Alternate Phone*

Country Code

Date of Birth*

Gender*

Type of Insurance*

Payor Name*

Plan Name*

If your insurance is not included in the available options, your coverage may not be accepted for services at UCLA Health. Please check with your insurance company for the most up-to-date coverage information.

Are you looking for primary care?*

Yes No

If you are a new patient, you can self-schedule an appointment with the provider of your choice or at the clinic location of your choice by selecting Book an Appointment.

If you are a current patient, please log into your myUCLAhealth account and visit the My Care Team tab to book an appointment with your doctor.

New and returning patients can also call a primary care clinic directly to schedule an appointment.

Select a Specialty*

If the specialty you're looking for is not listed, we are not able to process your appointment request using this form. Please visit our clinic locations directory at uclahealth.org/locations and call the clinic directly to schedule.

Parent or Guardian's First Name *

Parent or Guardian's Last Name *

Parent or Guardian's Phone Number *

Parent or Guardian's Email *

Is this your first time scheduling with a UCLA Health doctor?*

Yes No

Are you interested in seeing a specific doctor? If yes, please provide their name.

Have you had an appointment with this doctor in the last 3 years?*

Yes No

If you are a current patient, please log into your myUCLAhealth account and visit the My Care Team tab to book an appointment with your doctor.

Patient's Preferred Language*

Is an interpreter needed?

Yes No

Reason for Visit*

At which location would you like to schedule an appointment?*

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?

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