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

Welcome to the Center for Colorectal Surgery at UCSF Health. You probably have lots of questions, and we are here to help you. To request a new patient appointment using our secure online form, please answer the questions below. If you are an existing patient, please schedule using MyChart or give us a call.

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. 

Referral Required

We must have a referral from your physician before making an appointment unless you are self-referring and your insurance allows for it.

To Speak with a Representative in Person

(415) 885-3606 Center for Colorectal Surgery
(415) 885-7673 Center for Pelvic Physiology

* 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:    
Group No:
Subscriber No:
Do you have secondary or supplemental health insurance?
*Secondary Medical Plan:    
Group No:
Subscriber No:
* Do you have a physician referral?

Type of Visit

* Please check all that apply.  


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?


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


Additional Information

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