FACE-TO-FACE INTERPRETATION

Face-to-Face Interpretation Service Request

PALS for Health will be in contact with you via phone and/or email within 24 hours of receiving your request. Please contact us at info@palsforhealth.org or 213.553.1818 with questions / 1 hour minimum for all appointments & 1 hour minimum charge for last minute cancellations less than 24 business hours.

DHSP PROVIDERS ONLY:
1. Download and complete the
PALS for Health Client Referral Form.
2. Upload the completed client referral form directly on the form below OR
a) fax it to 213.553.1876
b) email to info@palsforhealth.org

DHSP Service Provider *

Yes No

Breast Cancer Related Appointment? *

Yes No

DHSP Providers ONLY: Upload Client Referral Form *

Max file size: 20MB

Contact Name *

First

Last

Email *

Phone Number *

Patient's Name *

First

Last

Patient's Gender *

Male Female Other

Patient's DOB *

Doctor's Name *

Doctor's Telephone *

Organization *

Organization Other (if not listed) *

Language Requested *

Today's Date *

Appointment Date *

Appointment Duration *

Appointment Time *

Purpose of Appointment *

Appointment Address *

Line 1

Line 2

City

State

Zip Code

Country

Additional Comments or Questions *

Submit

Click the button below for
Simultaneous/Conference Interpretation Requests

Simultaneous Interpretation Request Form

Face-to-Face Interpretation Service Request

Click the button below for Simultaneous/Conference Interpretation Requests

Click the button below for
Simultaneous/Conference Interpretation Requests