International Patient Center

Please fill out the form below in English to request an appointment and one of our international patient coordinators will contact you within one business day.

Required fields are marked with an*

Patient Information

Is the patient a new patient at the Massachusetts General Hospital International Patient Center?*   

First name*   

Last name*   

Date of birth (month/day/year)*   

Gender*   

Home address*   

City*   

State/province/region*   

Country*   

Postal code

Phone number (please include the country code)*   

E-mail address

Physician e-mail address (if referring a patient)

Type of appointment/referral request*   

Reason for appointment/referral*