To initiate the appointment process, please download and complete the following forms:
Please note that to schedule an appointment, a patient must be able provide access to the medical records from his or her cancer treatments. These records are a vital part of the survivorship consultation visit, and help to ensure that the VITA program can provide the best evaluation and recommendations for follow-up care.
After you have completed both forms, please contact Amy Jacobson, R.N., N.P.-B.C., at (310) 794-7525 or email AJacobson@mednet.ucla.edu to make an appointment.
Last updated: 12/19/2014 3:53:35 PM