Physician Referrals Online Form

Please use the secure form below to request a new patient appointment with one of our 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 Physician Referral Service at 1-800-MD-TO-BWH (1-800-638-6294). Our trained coordinators can also facilitate consultations and second opinions. If you are unsure of which Brigham and Women’s physician to contact, the coordinator can direct you to the appropriate faculty member. The Physician Referral Service is staffed Monday through Friday, 8:30am-5:00pm. After hours, you may leave a message which will be returned promptly on the next business day.

Fields marked with an asterisk (*) are required

Referring Physician or Staff Member Completing this Form

Is the patient aware of this referral?  *

Patient Information

Gender  *

Thank You for Submitting a Patient Referral

Your patient referral has been received. Our Physician Referral Service will contact your office within two business days, Monday through Friday, 8:30am-5pm.