Request an Appointment

Please fill out the form below and one of our new patient coordinators will respond within 24 hours, excluding weekends and holidays. Our new patient coordinators will explain the steps involved with becoming a patient at Dana-Farber/Boston Children's Cancer and Blood Disorders Center and help arrange your first appointment. When immediate care is required, we can typically accommodate new patients within 24 hours. If the child’s condition is life threatening and requires emergency care, dial 911.

You can also contact a New Patient Coordinator by phone.

For inquiries outside the United States call +1-617-632-2952

For translation services call 617-632-3673

Items in BOLD are required.

Patient Information
First Name:
Middle Name or Initial:
Last Name:
Street Address:
Street Address 2:
City:
State:
Province:
Zip/Postal Code:
Country:
Daytime Phone:
Evening Phone:
Cell Phone:
Fax Number:
E-Mail Address:
Date of Birth
Month:
Day:
Year:
Gender

Contact Information
Contact Name (if different from patient):
Contact Phone:
Relationship to Patient:
Medical Information
Diagnosis:          
If other, please specify:
Additional Clinical Information (i.e. test results, etc.):

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.

Rated One of Best Hospitals

US NewsRated one of best hospitals in the U.S. for childhood cancer care