Lung Transplant Physician Referral Form

Please use the secure form below to request a new patient appointment with one of our lung transplant physicians. Once the form is submitted, a trained coordinator will contact the patient to schedule an appointment. Referring physicians will be provided with the appointment details.

If you prefer to make the referral by phone, please call our Referral Coordinator at (617) 525-7614. Our trained coordinators can also facilitate consultations and second opinions.

This form is for providers. Patients can request an appointment using this form.

Fields marked with an asterisk (*) are required.

Please note: This form works best in Chrome, Firefox or Safari.

Referring Physician or Staff Member Completing this Form

Referrer: *Referrer First name: *Referrer Last name: *Referring physician NPI #:Referrer direct phone number: *Referrer email address: *Referrer fax number:Referrer preferred contact method (for status updates): *Organization/Practice name: *Practice mailing address: *City: *State/Province: *ZIP/Postal code: *Country: *Is the patient aware of this referral? *Preferred BWH provider or specialty area: *

Patient Information

Patient first name: *Patient last name: *Gender *Patient date of birth: *Patient daytime phone: *Patient email address: *Patient Address: *City: *State/Province: *ZIP/Postal code: *Country: *Reason for visit (Please include details of the diagnosis and the amount of oxygen the patient is using, if any): *

Please verify that you are not a robot by clicking on Submit Referral

Thank You for Your Lung Center Patient Referral Request

Your lung transplant patient referral has been submitted.

Lung Transplant Physician Referral Form

Referring Physician or Staff Member Completing this Form

Patient Information

Thank You for Your Lung Center Patient Referral Request

Error Submitting Form

Lung Transplant