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

* indicates a required field.

Please use this form only if:

  • You have never been a patient at Mass General, OR
  • You have been a patient at Mass General but are seeking an appointment with a new clinical area or doctor

Before we can schedule your appointment, you will need to obtain a Mass General Medical Record Number (MRN). If you have not received care at Mass General in the last six months, or if you have never received care at Mass General, please call 1-866-211-6588 (toll free) to verify your information and/or obtain an MRN.

Patient Information








MM/DD/YYYY








Requestor Information










If you are an international patient, please complete the International Patient Appointment Form.

Referring Physician



Wound Details

Please fax outside medical records to 617-724-0405