To refer a patient to the Connective Tissue Diseases Clinic, please submit the form below.

Thank you for your interest in the Connective Tissue Diseases Clinic at the Department of Dermatology at Massachusetts General Hospital. Often patients will have previously received treatments for their underlying disease but which still leave the patient with significant disease-associated problems such as disabling Raynaud’s, progressive skin scarring or hair loss. Our objective is to provide a comprehensive medical approach to all aspects of the patient’s condition.

To refer a patient, please fill out this form and submit it to our clinic coordinator. Most referrals are processed within a week. Our coordinator will inform you of the patient’s appointment date and time.

To facilitate evaluation of your patient, please provide the following information:

Required fields are marked with an*

Patient name*   

Best contact phone number*   

Street address

City

State

Zip code

Please provide a brief one or two line reason of why this patient is being referred: (please do not put one word responses, such as rash, explain the nature of rash). Example: Patient with new ANA and new rash on TNF-alpha concern for drug induced lupus

Referring physician name*   

Office phone*   

Fax

E-mail address

What is your medical specialty?