Refer a Patient | Dana-Farber/Boston Children's Cancer and Blood Disorders Center

If you are a medical professional and wish to refer your patient to Dana-Farber/Boston Children's, please call 1-888-PEDI-ONC (1-888-733-4662) or use the form below. One of our new patient coordinators will respond within 24 hours, excluding weekends and holidays. When immediate care is required, we typically can accommodate new patients within 24 hours.

You also may directly contact a specific treatment center.
If you are a parent or guardian interested in making an appointment for a child, please use our request an appointment form.
Families also may use our Online Second Opinion Program to receive a remote second opinion.
For inquiries outside the United States, call +1 617-355-5209.
For translation services, call 1-617-355-7198.

Patient Information

First Name

Middle Name or Initial

Last Name

Date of Birth

Month

Day

Year

Gender

Male

Female

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.

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