Refer a Patient

Please submit the secure form below to refer your patient to a provider in the Pain Management Center at Massachusetts General Hospital. Please do not fax a copy of this form.

After you submit this form, please fax the patient’s last visit note and recent imaging reports to 617-726-3441. Our office will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details. You may also speak with a representative directly Monday – Friday, 8:00 am to 4:30 pm EST by calling 617-726-8810.

Important note: Some questions on this form may appear or disappear based on your responses.

* indicates a required field.

Patient Information

First name

Last name

Date of birth

MM/DD/YYYY

Phone number (to contact the patient with appointment information)

Referring Physician

First name

Last name

NPI

Phone

Fax

Practice name

Address line 1

Address line 2

City

State

Zip Code

Preferred Method of Communication for Status Updates

Referral Information

Priority

To Provider

Location

Reason for referral

Please specify

Expanded reason for referral

Is this referral for a work-related injury?

Goal of therapy

Has the patient been seen by other pain specialists in the last 1-2 years?

We are unable to provide long-term opioid prescriptions. By accepting this term, the referring provider will be responsible for prescribing.

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Refer a Patient

Refer an International Patient