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Otolaryngology Appointment Request

To request an appointment with an ear, nose and throat specialist in Pediatric Otolaryngology, please complete the form below and click on "Submit." A representative will call you within one business day to begin the process of scheduling an appointment.

Please note that a referral from your doctor and authorization from your health insurance company may be required. Please fax these documents to (415) 353-2603.

This form is for new patients only. If you or your child are already a patient in this clinic, please use MyChart.

If you have any questions, comments or complaints about your appointment request, please use our Contact Us form.

This service is for non-urgent appointments only. If you have a medical emergency, please call 911.

* Required

Patient Information

New patient? Yes

Last Name*

First Name*

Middle Name

Date of Birth*

Contact Information

Are you the patient?

Yes No

Preferred Contact Method

Daytime phone*

Alternate phone

Best Time to Call Between 8 a.m. and 5 p.m., Monday - Friday

Medical Information

Medical Plan

Medical Group Number/Subscriber Number

Do You Have a Referral From Your Primary Care Doctor?

Yes No

Preferred doctor

First available doctor

Location and Time

Preferred Appointment Time

	M	Tu	W	Th	F
AM
PM

Select All Times
Clear All Times

Reason For Your Visit

Briefly describe the reason for your visit

Other comments

If you prefer to speak with a representative about making an appointment, please call Pediatric Otolaryngology – Head and Neck Surgery from 8 a.m. to 5 p.m., Monday to Friday.

Pediatric Otolaryngology - Head and Neck Surgery
2330 Post St., Suite 310
San Francisco, CA 94115
Phone: (415) 353-2757

For help selecting a doctor, please visit our online Physician Referral Directory. You can also reach our Referral Center at (888) 689-UCSF from 8 a.m. to 5 p.m. (PST) Monday to Friday, or by email at [email protected].

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