Share on facebook Share on Twitter Share on Google Plus Share This

Physician Access Intake Form (Providers + Staff Only)

Referring a patient has never been easier. Simply fill out our refer a patient form and one of our referral coordinators will immediately follow up with you. Having trouble? No problem. Just call our Physician Access Line at 617-636-7255.

This form should only be filled out by physicians or their staff.

This site is not designed to and does not provide medical advice, professional diagnosis, opinion, treatment or services to you or to any other individual. See more information.

In the case of a medical emergency, please call 911 for immediate assistance.

Obstetrics and Gynecology Division

Tufts Medical Center
800 Washington Street, Box 324
Boston, MA 02111


Women's Care South

Braintree Hill Office Park
15 Rockdale Street, Suite 201
Braintree, MA 02184

Tufts MC Specialty Center - Norfolk

31 Pine Street
Norfolk, MA 02056

South End Community Health Center

1601 Washington St.
Boston, MA 02118

* Indicates a required field.


Patient Information

Marital Status
Interpreter Required?

Insurance Information