Please submit the secure form below to refer your patient to a provider at Massachusetts General Hospital. This form should not be used for appointments needed within 72 hours. In those cases, please call 617-726-2000 to be connected to the appropriate practice.

After you submit this form, a member of the clinical team will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details. Important note: Some questions on this form may appear or disappear based on your responses.

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Referring Provider Information
Patient Information