Vascular Surgery Labs & Centers
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Request an Appointment - Vascular and Endovascular Surgery

To request an appointment, please complete the form below. If you are a physician or health professional, please use our Physician Referral Form.

Appointments may also be requested directly by calling the Vascular & Endovascular Surgery clinic at (415) 353-2357. Please note that a physician referral and health insurance authorization are both required. Please fax these to (415) 353-2669.

For Marin County (Greenbrae) Appointments
Patients are seen at our Greenbrae clinic on the 2nd & 4th Mondays of the month. Please indicate your preference to be scheduled at Greenbrae in the "Additional Information" section at the end of this form.

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

Note: This is a request only and subject to program restrictions and availability. This is a secure form and any information provided will be handled in strict compliance with applicable privacy laws.

* indicates required field

Patient Information

 
* First Name:
  
* Last Name:
 
* Address:
  
Apartment/Suite No:
* City:
  
* State:
     
* Zip / Postal Code:
     
* Country:
  
* Daytime Phone No:
    
Alternate Phone No:

Email Address:
* Date of Birth:

Example: 02/20/1980
 
* Gender:
 
How did you hear about UCSF?

Relationship to Patient

* Are you the patient?:

Physician Information

Name of Primary Care Physician:
Primary Care Physician's Phone:
Name of Referring Physician:
(if different from primary care doctor)
Referring Physician's Phone:

Insurance Information

Select your medical plan from the dropdown list. If not listed, type the plan into the box “Other”.
* Medical Plan:     
  Other: 
  Group No: 
  Subscriber No: 
Do you have secondary or supplemental health insurance?
* Do you have a physician referral?
 

Type of Visit

* Please check all that apply.   


  Other:

Reason For Appointment

* Please indicate the nature of your medical issue or problem below.   

Desired Physician or Provider

If you have a physician or provider preference, please make your selection here.

Desired Physician or Provider:  
Have you seen this provider before? 

Diagnosis

If applicable, select your diagnosis from the dropdown list. If not listed, then type the diagnosis into the box labeled "Other".
Diagnosis:       

Other:

Diagnostic Tests

Please check all tests performed to diagnose your condition.





Other:

Treatment History

* Have you ever been treated for this disease/condition?  
If yes, please check all treatments (past or current) that apply.



Other:
If you checked Surgery above, please provide the date of the most recent surgery.
   
Have you ever participated in a clinical trial for this condition?

 Additional Information

Please provide any other relevant information about your treatment in the space below.
Please review the information you provided above. A UCSF Vascular & Endovascular Surgery Program Specialist should be contacting you within 1-2 business days.
     

 


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