Lung Center Physician Referrals Online Form

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-BWH-LUNG (1-844-294-5864). Our trained coordinators can also facilitate consultations and second opinions. If you are unsure of which Brigham and Women’s physician to contact, the coordinator can direct you to the appropriate faculty member. The Physician Referral Service is staffed Monday through Friday, 7:30am-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

Referrer: *Referrer First name: *Referrer Last name: *Referring physician NPI #:Referrer direct phone number: *Referrer email address: *Referrer fax number: *Referrer preferred contact method (for status updates): *Organization/Practice name: *Practice mailing address: *City: *State/Province: *ZIP/Postal code: *Country: *

Is the patient aware of this referral? *

YesNo

Preferred BWH provider or specialty area: *

Patient Information

Patient first name: *Patient last name: *

Gender *

MaleFemale

Patient date of birth: *Patient daytime phone: *Patient email address: *Patient Address: *City: *State/Province: *ZIP/Postal code: *Country: *Reason for visit: *

Please verify that you are not a robot by clicking on Submit Referral

Thank You for Your Lung Center Patient Referral Request

Your Lung Center patient referral has been submitted.

Lung Center Physician Referrals Online Form

Referring Physician or Staff Member Completing this Form

Patient Information

Thank You for Your Lung Center Patient Referral Request

Error Submitting Form

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