Referral Form: Pediatric Specialties

The Physician Referral form is an easy way for doctors to refer patients to MassGeneral Hospital for Children specialists. The Access center will call your patient within 1 business day.

  • To refer by phone, please call 888-644-3211 for immediate assistance during business hours

If you have an urgent referral, please call 888-644-3211.

  • For information about our pediatric specialists, please see our online directory.
  • Please note you may print the completed form for your patient using the "Print This Page" icon above.
  • For ENT/Optho referrals, please call 617-573-3190.
  • The Access & New Appointment Center will call your patient within 1 business day.

Required fields are marked with an*

Patient name*   

Patient phone*   

DOB or MRN*   

Specialty*   

If other, please specify

1st appointment or preferred specialist*   

If preferred, please specify

Reason for referral*   

Additional instructions/Hx

Referring provider name

E-mail for confirmation (optional)