门诊预约

如果您需要预约医生，或者您为您的病人提出转诊要求，请填写一下表格。该表格要求用英文填写。我们在收到您填写的表格后，将在一个工作日内与您联系。如果您需要跟我们电话联系，请致电+1-617-726-2787。

重要提示：根据您的回答，此表单上的某些选项可能会出现或消失。

如果你是美国本土患者，请填写美国患者门诊预约表格。

* 是必填的选项

Patient Information

Have you ever been a patient at Massachusetts General Hospital?

Mass General Patient Medical Record Number

First Name

Middle Initial

Last Name

Date of Birth

Day

Month

Year

Are you 18 or older?

Gender

International Home Address

City

Province/Region

Postal Code

Country

Cell Phone

Country and City Code

Home Phone

Country and City Code

Email Address

Reason for Requested Visit/Clinical Diagnosis

Emergency Contact Information

Contact Relationship

Insurance or Payment Options

How do you expect to pay for your care?

Insurance Policy

Insurance Group Number

Insurance Phone

Insurance Name

Anticipated Travel Information

Month

Day

Year

Will you require an interpreter during your visit at Mass General?

The Mass General Difference