Refer a Patient

Despite the challenges to the entire healthcare community posed by COVID-19, Dana-Farber remains undeterred from our mission to provide expert, compassionate care. We are still caring for current patients, accepting new patients, and providing second opinion consultations.

Our strong commitment to safety remains unchanged, and we have taken numerous additional steps to protect our patients and staff.

By phone

To refer an adult patient, call 877-441-3324.
To refer a pediatric patient, call 888-733-4662.

Online

Please fill out and submit this form. A New Patient Coordinator will contact your office within 24 hours, excluding weekends and holidays. Our regular business hours are 9:00 a.m. – 5:00 p.m. ET.

Items in BOLD are required.

Patient Information
First Name:
Middle Name or Initial:
Last Name:
Date of Birth:Month:     Day:     Year:

   
Gender:
Diagnosis Information
Diagnosis:
If other, please specify:
Additional Clinical Information (i.e. test results, etc.):
Physician Information
First Name:
Last Name:
Contact Name:
Address:

Address 2:
City:

State:
or Province:
Zip/Postal Code:

Country:
Phone:

Fax:
E-Mail:
     Check here if e-mail is the preferred contact method.
Additional Information
Physician Referred to (if applicable):
Patient Phone:
OK to contact patient directly?

Enter the code shown above:

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We take privacy very seriously and make every effort to maintain your full confidentiality. Before using this form you should be aware of our Privacy Policy.