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.

Patient Information













International Permanent Address






Country and City Code

Country and City Code




Primary Contact Information
If another individual will be helping to coordinate the patient's care, please include the primary contact's information below.  Please note, for patients under the age of 18, we require a parent or legal guardian’s contact information.








Country and City Code

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