Refer a Patient

Thank you for your interest in the Lester and Nancy Fraser Burn Center at Mass General. Once we have received your completed form, a representative will contact your patient within one business day to schedule an appointment.

You may also refer a patient by phone: 617-726-3712
For immediate advice, call 617-283-8186
For urgent transfers, call 1-800-678-2876

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

* indicates a required field.

Patient Information

First name

Last name

Date of birth

MM/DD/YYYY

Phone number (to contact the patient with appointment information)

To facilitate processing, please provide Insurance Plan Name if known

Is the patient aware of this referral?

YesNo

Describe reason for referral and Include ICD10 code if known

Referring Physician

First name

Last name

Are you the referring Physician?

Yes

NPI

Phone

Fax

Practice name

Address line 1

Address line 2

City

State

Zip Code

The Mass General Difference

Conditions & Treatments

Patients & Visitors

Research & Innovation

Burns

Refer a Patient

Refer a Patient

Telehealth at Mass General