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

  • You may also schedule an appointment by phone: 617-726-3872 (option 6)

Thank you for your interest in the Thyroid Nodule 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

Email address

Primary insurance*   

Secondary insurance

Is your patient aware of their diagnosis?*   

Please provide any additional information you think may be important for us to know about the patient being referred (if any):

Patient Previous Testing (check all that apply)

Thyroid ultrasound  
Biopsy of thyroid nodule(s)  
Biopsy showed a suspicous or cancerous result  

Referring Physician Information

Referring physician name*   

Preferred phone*   

Email address*   

Fax

Street address

City

State

Zip code