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 Faulkner Hospital 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
Referring physician NPI #
*Direct phone number
*Preferred contact method (for status updates)
*Practice mailing address
*Is the patient aware of this referral?
*Preferred BWHFH provider or specialty
*Date of birth (mm/dd/yyyy)
*Reason for visit