Please fill out the form below to request an appointment for your patient with the Gastroesophageal Surgery Program at Massachusetts General Hospital.

  • You may also schedule an appointment by phone: 617-724-1020

Thank you for your interest in the Gastroesphageal Surgery Program at Massachusetts General Hospital. Once we have received your completed form, our care coordinator will contact you within one business day to schedule an appointment for your patient.

Required fields are marked with an*

Patient Information

Patient name*   

Date of birth*   

Preferred phone*   

Street address

City

State

Zip code

E-mail address

Primary insurance*   

Secondary insurance

Patient clinical history (check all that apply)

Achalasia  
Asthma/cough  
Dysphagia/odynophagia  
Esophageal Diverticulum  
Gastroesophageal Reflux Disease (GERD)  
Hoarseness  
Fundoplication  
Gastric cancer  
Esophageal cancer  
Paraesophageal hernia  
Please provide any additional information you think may be important for us to know, such as unusual features of the case or patient being referred (if any):

Patient previous testing (check all that apply)

Barium swallow  
CT scan/PET scan  
EUS  
Manometry  
pH testing  
Tissue biopsy  

Referring Physician Information

Referring physician name*   

Preferred phone*   

E-mail address*   

Fax

Street address

City

State

Zip code