Refer a Patient

If you are a physicians and medical professionals who would like to refer a patient to Dana-Farber/Boston Children's Cancer and Blood Disorders Center, please fill out the form below and one of our new patient coordinators will respond within 24 hours, excluding weekends and holidays. When immediate care is required, we can typically accommodate new patients within 24 hours.

If you are a parent or guardian of a patient interested in making an appointment for a child, please use our request an appointment form.

You can also contact a New Patient Coordinator by phone

For inquiries outside the United States call +1-617-355-5209

For translation services call 617-632-3673

Items in BOLD are required.

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

Medical Information
Diagnosis:
If other, please specify:

Additional Clinical Information (i.e. test results, etc.):
Referring Physician Information
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.

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