Please submit the secure form below to refer your patient to a provider at Massachusetts General Hospital. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 617-726-2784.

After you submit this form, our office will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details. You may also speak with a representative directly Monday – Friday, 8:30 am to 5:00 pm EST by calling 617-726-2784.

If this is a Spine referral, please call our Spine Center at 617-724-8636

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

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Patient Information


Spine referral, please call our Spine Center 617-724-8636

Referring Physician