Surgery Websites
Bariatric Surgery »  Patient Center »  RAA Form
Request an Appointment

To request an appointment online, please complete the form below.

New Patient Appointments by phone may also be made by calling:
(415) 353-2804 (Bariatric New Patient Coordinator). 


Follow up appointments may be made by calling:
(415) 353-2161 (Bariatric Clinic Front Desk)

If you are a physician or health professional, please use our Refer a Patient Form. This service is for non-urgent appointments only. If you have a medical emergency, please call 911. This is a secure form and any information you provide will be handled in strict compliance with applicable privacy laws.

We currently do not accept Medicare coverage or Medi-Cal coverage for patients who reside outside of San Francisco.

NOTE: All appointment requests are subject to program restrictions, guidelines, and availability.
* 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:

* 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?
*Secondary Medical Plan:  
Other:
Group No:
Subscriber No:
* 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?

Additional Information

Please provide any other relevant information about your treatment in the space below.

Please review the information you have provided above, then click the "Submit' button". A UCSF Patient Coordinator should be contacting you within 5-7 business days. Should you have any additional questions or concerns, for new patient appointments  please call (415) 353-2804 (Bariatric New Patient Coordinator). Follow up appointments may be made by calling (415) 353-2161 (Bariatric Clinic Front Desk).

 
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