Please use this form only if:
  • You have never been a patient in the Pancreas Transplant Program, OR
  • You have been a patient in the Pancreas Transplant Program but are seeking an appointment with a new clinical area or doctor
Whether you require a kidney/pancreas transplant or a pancreas after kidney transplant, your first appointment will be a comprehensive pre-transplant evaluation that includes medical and surgical consultations, laboratory tests and specialized procedures to determine if you are a candidate for transplantation. Before we can schedule your pre-transplant evaluation, you will need to do the following:
  • Submit the secure form below
  • 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.

After you submit the form, a transplant nurse coordinator and a transplant nephrologist will review the information you submit and contact you. You may also speak with a representative directly Monday–Friday, 8:30 am to 5:00 pm EST by calling 877-644-2860.

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

* indicates a required field.

Please call 911 if you are experiencing a medical emergency.

Requestor Information

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

Patient Information


Referring Physician