Refer a Patient: Barrett’s Esophagus Treatment Center

To refer a patient, please submit the form below. One of our access coordinators will contact you within two business days.

  • You may also refer a patient by phone: 617-726-0607

Thank you for your interest in the Barrett’s Esophagus Treatment Center at Massachusetts General Hospital.

Patient medical documents will be reviewed within two business days of receipt and you will receive notification of the patient's referral status. If your patient meets the program criteria, you will receive a letter confirming his/her scheduled appointment.

To facilitate evaluation of your patient, please fax copies of the patient’s medical records (including all endoscopy reports within the past five years) to 617-724-5997.

Required fields are marked with an*

Patient Information

Patient name*   

Best contact phone number*   

Street address

City

State

Zip code

Prior patient diagnosis (please check all that apply)*

GERD  
Barrett’s esophagus without dysplasia  
Barrett’s esophagus with dysplasia  
Esophageal cancer  
HX of prior treatments (RFA, cryotherapy, EMR, esophagectomy)  

Referring Physician Information

Referring physician name*   

Office phone*   

Fax

E-mail address

Mobile phone number

What is your medical specialty?*