One-Time Request Disclaimer

Please read before proceeding to fill out the form

By clicking on the one-time request form button below, you acknowledge and consent to the following important disclaimers:

• The one-time request portal has no save feature. Please make sure to have all necessary information and documentation (e.g. vendor quote, FDA 510k, PMA approval, etc.) prior to starting your submission form.

• Requestors must reattach all files to the form during the second attempt if an error occurred during original submission (e.g. a user forgets to fill in the required "manufacturer" field. The request will not go through and an error message will appear. He/She must attach the "copy of FDA 510k or PMA approval" and all other required file attachment fields again during the resubmission.

• The one-time request portal is intended for UCLA Health only. Users must be connected to the UCLA network (intranet) to access all one-time request forms.

One-Time Request Form