Request an Appointment: Kidney Transplant Program

Please fill out the form below to request an appointment. One of our intake coordinators will contact you within one business day.

  • You may also schedule an appointment by phone: 877-644-2860

If you are experiencing a medical emergency, call 911 or go to your local emergency room.

Thank you for your interest in the Kidney Transplant Program at the Massachusetts General Hospital Transplant Center. 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:

  1. Submit form below
  2. Send medical documents (see full list (PDF))
  3. 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

Once we have received your medical documents and the form below, a kidney transplant nurse coordinator and a transplant nephrologist will review them to determine if a transplant evaluation appointment is appropriate at this stage in your care plan.

Required fields are marked with an*

Patient Information

Patient name*   

Date of birth (MM/DD/YEAR)*   

Home phone*   

Cell phone

Street address*   

City*   

State*   

Zip code*   

E-mail address

Preferred method of communication

Primary insurance*   

Secondary insurance

Are you currently listed at another transplant center?*   

Have you been evaluated for a transplant in the last year?*   

Have you ever received a transplant?*   

Mass General Medical Record Number (MRN)

Referring Physician Information

Referring physician name*   

Phone*   

Fax*   

Street address*   

City*   

State*   

Zip code*   

E-mail address

What kind of doctor is your referring physician?*   

Dialysis Information

Are you currently on dialysis?*   

If yes, what type of dialysis are you on?

Dialysis Center Information (for patients on dialysis)

Center name

Phone

Fax

Street address

City

State

Zip code

Hemodialysis schedule

Peritoneal Dialysis schedule