(855) IBD-UCLA / (855) 423-8252
- The form serves as fax cover sheet and physician order.
- Once the information is completed just fax the form, with records and insurance information, to the number is listed at the bottom of the form.
- Please feel free to download the form as you can type directly onto the pdf or make copies for your files.
We are located in Westwood >
Vatche and Tamar Manoukian Medical Building
100 UCLA Medical Plaza #345
Los Angeles, CA 90095