Neurology Outpatient Consultation Request & Referral Form
Select the requested sub-specialty below or write MGH neurologist’s name
Sub-specialty
Fax
Sub-specialty
Fax
ALS
617-643-2590
Muscular Dystrophy
617-726-2019
Ataxia
617-726-6991
Multiple Sclerosis
617-726-6991
Autism, Lurie Center for
781-860-1766
Nerve Injury
617-726-6991
Cognitive Behavioral Neurology
617-726-6991
Neurology-Infectious Disease
617-726-6991
Dystonia
617-726-2019
Neuro-ophthalmology
617-726-6991
Epilepsy, adult
617-726-9250
Neurofibromatosis
617-724-8769
Epilepsy, pediatric
617-726-0230
Neurogenetics Program
617-724-9620
Frontotemporal Disorders
617-726-4101
Neuromuscular, adult
617-726-6991
General Neurology, adult
617-726-6991
Neuromuscular, pediatric
617-724-7860
General Neurology, pediatric
617-724-7860
Otoneurology
617-724-0895
Huntington’s
617-726-4101
Painful Neuropathy
617-726-2019
Learning Disorders
617-726-3979
Parkinson’s
617-726-4101
Leukodystrophy
617-726-4101
Sleep, adult
617-724-6513
Lysosomal Disease
617-726-0230
Sleep, pediatric
617-724-7860
Memory Disorders
617-726-4101
Stroke
617-726-8459
Movement Disorders
617-726-4101
Tourette Syndrome
617-726-4101
*Important  Non-MGH patients: Register with the Registration & Referral Center at 1-866-211-6588 to
obtain a MGH ID # before we can schedule an appointment.
Referring Provider Information
Requested by
Phone
Fax
Full name
Provider Number
Address
Reason(s) for consultation
* Important  Non-Partners affiliated physicians: Please fax the medical history and test results pertaining to
this consultation only. Please avoid sending records that are unrelated to the Neurology consult.
Patient Information (Neurology will schedule the appointment directly with the patient.)
Patient Name
MGH ID #
Insurance Referral #
Date of Birth
Home Phone
Work Phone
Name of contact person if different from patient
Home Phone
Work Phone
To contact any department directly please call the Neurology Access Center: 1-855-MGH-NEUR
(1-855-644-6387; 617-724-6387) Business Hours: 8:00 am to 5:00 pm
Note: MGH Neurology does not have a headache subspecialty program or provide consults for disability determination. Please call Neurology at 1-855644-6387, or visit Neurology on the Web at www.massgeneral.org/neurology with any questions. Thank you.
Updated: 4/29/2013. Approved: JC, Operations & Project Manager
Version 7