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Interventional Radiology 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 ›

Already a patient?

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

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.

What to expect: 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 details and any other pertinent information available.

An asterisk (*) indicates a required field.

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

Patient first and last name

Are you the patient? Yes No

Your name, if you are not the patient

Email address

Best number to call you. Please include your area code.

Best time to call you
Morning (8 a.m.-noon) Afternoon (1 p.m.-5 p.m.)

Reason for your request