Pediatric Brain Center Appointment Request

To request an appointment with a pediatric primary care doctor, please complete the form below and click on "Submit." A representative will contact you within one business day to schedule an appointment.

Please note that currently we are not accepting online appointment requests for new patients at the Pediatric Brain Center.

This form is for new patients only. If your child is already a patient in this clinic, please request an appointment using the patient portal 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

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

Contact Information

Yes No

Medical Information

First available doctor

Referral Information

Yes No

Please note that a referral from your doctor and authorization from your health insurance company are required. Please fax these documents to (415) 353-2633.

Reason For Your Visit

 

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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