Request an Appointment

Samueli Center Appointment Request

Please use this form only if you are a new patient or making an appointment for a patient.

If you are an existing patient, please log in to the patient portal to submit your appointment request ›

After you submit your request, a UCI Health representative will contact you by phone within one business day to assist in making an appointment.

Medical emergencies

Call 911 if you are experiencing an emergency. Do not use this form.

Patient Information
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Preferred appointment day


Preferred appointment time
Are you the patient?

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This field is optional, but providing this information will expedite processing.
This field is optional, but providing this information will expedite processing.
Patient date of birth (mm/dd/yyyy)
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If you are not the patient, enter your contact information below.
What is your relationship to the patient?



Additional Information
Best time to call?


 
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