Thank you for your interest in Massachusetts General Hospital for your healthcare needs.  We are honored to be of assistance.  In order to best assist you, please complete the below form.  Once submitted, a member of the International Patient Center team will follow up to guide you through your journey to health.

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

* indicates a required field.

Primary Contact
If you are completing the form for someone else, please include patient's primary contact's information below. 

Country and City Code

Patient Information

International Permanent Address

Country and City Code

Country and City Code

Please note: to visit the US for medical care, you may need to obtain a nonimmigrant visa (B-2). Documented proof of sufficient funds may be required to cover all costs related to your travel, in addition to hospital and physician fees. Please visit Visitor Visa ( for detailed visa requirements.

Additional Details
Preferred Travel Dates
Preferred Travel Start Date
Preferred Travel End Date