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Scheduling for Surgery

Welcome to the centralized online surgery scheduling page for UCI Health — Fountain Valley, UCI Health — Lakewood, UCI Health — Los Alamitos and UCI Health — Placentia Linda. Use the form below to schedule surgeries for your patients.

UCI Health — Fountain Valley

In order to successfully submit the form, please ensure that all fields marked with an asterisk (*) are completed.

Today's date

Date of procedure

Time of procedure (please denote a.m. or p.m.)

At which location will the surgery occur? UCI Health — Fountain Valley UCI Health — Lakewood UCI Health — Los Alamitos UCI Health — Placentia Linda

Patient Name (Last, First)

Date of birth

Sex Male Female Nonbinary

Primary/Preferred Language

Contact number

Cell phone number

Best Time to Call

Address (street number, street name, apt. #, suite)

City

State

ZIP code

Social Security Number

Emergency Contact, Name, Phone #

PT From Home

Skilled Nursing

Skilled Nursing Detail

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