Request an Appointment

Complete this secure form and a member of our team will contact you to schedule your appointment as soon as possible. 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.

For faster service, please call the Department or Division office directly.

In the case of a medical emergency, please call 911 or visit your local Emergency Room for immediate assistance.

---

* Indicates a required field.

Select Specialty	Please Select Allergy Pediatric Anesthesiology Pediatric Audiology Pediatric Cardiac Surgery Pediatric Cardiology Pediatric Center for Adoptive Families Pediatric Child + Adolescent Psychiatry Pediatric Complex Care Pediatric Critical Care Medicine Pediatric Dentistry Pediatric Dermatology Pediatric Center for Children with Special Needs Pediatric Hospitalist Medicine Pediatric Newborn Medicine Pediatric Ear, Nose, Throat / Otolaryngology Pediatric Gastroenterology Pediatric General Surgery Pediatric Genetics + Metabolism Pediatric Gynecology Pediatric Infectious Diseases Pediatric Nephrology Pediatric Neuro Pediatric Occupational Therapy Pediatric Ophthalmology Pediatric Pathology + Lab Medicine Pediatric Physical Medicine + Rehabilitation Pediatric Physical Therapy Pediatric Plastic Surgery Pediatric Radiation Oncology Pediatric Radiology Pediatric Rheumatology Pediatric Speech Language Pathology General Pediatrics and Adolescent Medicine Pediatric Trauma Surgery
What is your preferred appointment type?	Please Select In Person Telemedicine
Who will be seeing the doctor?	Me Someone Else
Patient Name Last Name
Has the patient received care at Tufts Medical Center before?	Yes No
Patient Date of Birth
Gender assigned at birth	Male Female
Street Address
Zip Code
Contact Name Contact Name	Check if same as Patient Name
Contact Email
Daytime Phone
Best Time of Day to Contact	Please Select Afternoon Morning
	I’d like to receive Tufts Medical Center news and health information.
Comments
	Submit Cancel | Clear Form