Please submit the secure form below to refer your patient to a provider in the Gastroesophageal Surgery Program at Massachusetts General Hospital. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 617-724-1020.

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 617-724-1020.

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

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Patient Information


Referring Physician

If you selected Physician Gateway above and are not currently enrolled, you will receive an email including enrollment instructions within 3 business days.

Physician Gateway is our secure online portal which enables you to submit referrals for patients, monitor patient status and order imaging tests.

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