Appointment Request Form

Call 911 IF THIS IS AN EMERGENCY

Be sure to bring any diagnostic films or other test results that may have been
ordered or performed by another physician.

*Please note: DEPENDING ON THE SERVICE YOU SELECT, AN ORDER FORM FROM YOUR
PHYSICIAN MAY BE REQUIRED in order for us to process your appointment request.
If you do not have an order, our staff will ask you to contact your referring
physician's office.

Please do not use this form if you have an
urgent medical problem or you need to re-schedule an existing appointment.
Instead, please contact our office at (323) 725-5066.

* The Wound Care Center is open Monday thru Friday, from 8:00 am to 5:00 pm.

Please Note: Call
911 if this is an emergency. Please
keep in mind that this form will generate a request for an appointment. Someone
will contact you within 2 business days to confirm the availability. Please call
(323) 725-5066 If you need your appointment sooner.

Any information submitted using this form is
transmitted securely and held in the strictest of confidence, protecting your
privacy.

* = Input is required