UCLA Health Interpreter Request Form

Fill out this form to schedule an interpreter and please provide as much lead-time as possible. Please provide at least 72-hours of advanced notice (not including weekends) for language service requests.

Urgent/critical requests for an interpreter please call x77804 or x77805 to connect with an over-the-phone interpreter (OPI).

Requestor's Information

First Name

Last Name

Mednet Email Address

Phone number

Patient Information

First Name

Last Name

MRN

Date of Birth (mm/dd/yyyy)

Appointment Information

Department Name

Location

Street Address (please include Suite #)

Language

Language if not listed, please type

Appointment Date

Appointment Time (24 hr format)

Duration

Transplant

Yes
No

If answered "yes" to the above question, please select the type of Transplant

Research Appointment

Yes
No

Interpreter Service Type

In-person
Phone
Zoom
My Chart / Telehealth

Enter Zoom Link

Appointment Type

Additional Information / Diagnoses