Please use this form only if:
  • You have never been a patient in the Burn Center, OR
  • You have been a patient in the Burn Center but are seeking an appointment with a new clinical area or doctor

After you submit the form, a representative will call you back with the information you’ll need to make an appointment. You may also speak with a representative directly Monday–Friday, 8:30 am to 5:00 pm EST by calling 617-726-3712.

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

* indicates a required field.

Please call 911 if you are experiencing a medical emergency.

Standard Intake Form

Request an Appointment: Lester and Nancy Fraser Outpatient Burn Center 

To make an appointment by phone please call:617-726-3712

Please fill out the form below to request an appointment with the Lester and Nancy Outpatient Burn Center at Massachusetts General Hospital. Upon receiving your completed form, our patient service coordinator will be in touch to schedule an appointment.

Patient Information








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Requestor Information










If you are an international patient, please complete the International Patient Appointment Form.

Referring Physician



About Your Appointment