Refer a Patient: Kidney Transplant Program

Please fill out the form below to refer a patient. One of our intake coordinators will contact you within three business days.

  • You may also refer a patient by phone: 877-644-2860

Thank you for your interest in the Kidney Transplant Program at the Massachusetts General Hospital Transplant Center. To refer a patient, please submit the form below and send the required medical documents:

  1. Recent history of physical exam (include height and weight or BMI)
  2. Recent hospital discharge summary if the patient has been hospitalized in the last year

Send medical documents by fax to 617-726-0822 or scan and email to MGHKidneyTransplant@partners.org
Please note: Security and confidentiality of email transmission is uncertain. The risk of data disclosure due to email transmission must be assumed by the sender.

Patient medical documents will be reviewed within three business days of receipt and you will receive notification of the patient's referral status.

For urgent referrals or transfer requests, call 617-726-2000 and ask the Page Operator to page the transplant surgeon on-call.

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

Primary insurance*   

Secondary insurance

Is the patient currently listed at another transplant center?*   

Has the patient been evaluated for a transplant in the past?*   

Has the patient ever received a transplant?*   

Referring Physician Information

Referring physician name*   

Phone*   

Fax*   

Street address*   

City*   

State*   

Zip code*   

E-mail address*   

Preferred method of communication

What is your medical specialty?*   

Dialysis Information

Is the patient currently on dialysis?*   

If, yes, which modality?

Dialysis Center Information (if applicable)

Center name

Phone

Fax

Street address

City

State

Zip code

Hemodialysis schedule