Appointment Request

Please do not use this form to schedule a COVID-19 vaccine appointment. For COVID-19 vaccine availability and scheduling, visit vaccine.ucihealth.org ›

Please use this form only if you are a new patient or making an appointment for a patient. If this is a medical emergency, please dial 911.

After you submit your request, a UCI Health representative will contact you by phone within one business day to assist in making an appointment. We also recommend having your insurance information and any other pertinent information available.

An asterisk (*) indicates a required field.