The Division of Thoracic Surgery

New Patient Appointment/Referral Form

Obtain a new appointment for yourself or a patient, by completing the New Patient Appointment/Referral Form. Forms submitted during normal business hours (7:30 a.m. to 5:00 p.m. EST) will be answered within 15 minutes. The form is emailed directly to our New Patient Coordinator team. One of our Patient Coordinators will contact you to schedule the appointment, answer any questions you may have, and provide additional information. If you prefer, you may call our Patient Coordinators directly at 617-732-5922.

If you do not have a referring doctor or if you are unsure of the diagnosis, you may leave those fields blank.

Please note: All fields marked with an asterisk (*) are required.

*Patient's Full Name
*Street Address
*City
*State
*Zip Code
*Country
*Daytime Phone
*Evening Phone
Referring MD
Referring MD's Phone
Diagnosis
Thoracic Surgeon
You do not need to choose a surgeon at this time.
*Contact Person
*Contact Phone
*Contact Email
*Relationship to Patient

Comments

Email Email our Administrative Director for comments about this website.

©2014, Division of Thoracic Surgery at Brigham and Women's Hospital. All rights reserved.

NOTICE: This email is not for medically related issues. Comments or concerns regarding patient-related care should be directed to the Thoracic Surgery Clinic at 617-732-6824.

Division of Thoracic Surgery
Brigham and Women's Hospital
75 Francis Street
Boston, MA 02115

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