Request an Appointment

Thank you for your interest in Massachusetts General Hospital for your healthcare needs. We are honored to be of assistance. In order to best assist you, please complete the below form. Once submitted, a member of the International Patient Center team will follow up to guide you through your journey to health.

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

* indicates a required field.

For whom do you seek care?

Primary Contact

If you are completing the form for someone else, please include patient's primary contact's information below.

Contact Relationship

Preferred Title

First Name

Last Name

Phone Number

Country and City Code

Email Address

Patient Information

Have you ever been a patient at Massachusetts General Hospital?

Mass General Patient Medical Record Number

Preferred Title

First Name

Middle Initial

Last Name

Gender

Date of Birth

Day

Month

Year

Is the patient 18 or older?

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Parent/Legal Guardian Day of Birth

Parent Legal Guardian Month of Birth

Parent/Legal Guardian Year of Birth

International Permanent Address

Mobile Phone

Country and City Code

Home Phone

Country and City Code

Email Address

Street (including Apt/House/Block #)

City

Province/Region (optional)

Postal Code

Country

Reason for Requested Visit/Clinical Diagnosis

Will you require an interpreter during your visit at Mass General?

What is your primary language?

Do you require assistance with a visa letter for this appointment?

Please note: to visit the US for medical care, you may need to obtain a nonimmigrant visa (B-2). Documented proof of sufficient funds may be required to cover all costs related to your travel, in addition to hospital and physician fees. Please visit Visitor Visa (state.gov) for detailed visa requirements.

Additional Details

Preferred Travel Dates

Preferred Travel Start Date

Preferred Travel End Date

Please indicate your primary coverage?

Self PayCommercial InsuranceGovernment

Insurance/Government Name

How did you hear about us?

Please provide the referring physician's name.

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