Specialist Referral Form for Referrals outside the MassGeneral Brigham Network

Please submit the secure form below to refer your patient to a provider from Patriot Pediatrics. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 781-674-2900.

After you submit this form, 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, 8:30 am to 5:00 pm EST by calling 781-674-2900.

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

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