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Department of Neurosurgery New Patient Referral Form

Thank you for your interest in the UCLA Department of Neurosurgery. Please fill out the form below and one of our friendly staff will contact you to make an appointment.

For assistance in determining which UCLA neurosurgeon(s) may have expertise to help you, please call the UCLA Neurosurgery Referral and general information phone number (310) 825-5111.

Our Referral and New Patient Intake process as follows:
  1. Provide information requested in the attached PDF to our referral specialist.
  2. Fax, mail, drop off medical records and films to fax/address provided to you by our referral specialist.
  3. You will be contacted by the neurosurgeon's office you were referred to, within 2 working days. At this time the physician's patient care coordinator will verify if your information was received or not, or if additional information is needed.
  4. Once your records are received and reviewed, an appointment with the neurosurgeon will be made as appropriate.
Patient Information
Type of Appointment
1. Contact Information of Person Requesting a Referral