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Patients and Referring PhysiciansKEPT PRIVATE IN ACCORDANCE WITH PARTNERS' CONFIDENTIALITY POLICIES,AND WILL BE SEEN BY A LIMITED NUMBER OF AUTHORIZED INDIVIDUALS ASNECESSARY, INCLUDING CERTAIN HEALTH CARE PROVIDERS AND THE INTERNATIONALPATIENT COORDINATORS. IF YOU NEED TO CHANGE THIS INFORMATION, PLEASECONTACT US (FAX: +1 (617) 535-6410, OR PHONE: +1 (617) 535-6400).WE MAY CONTACT YOU IF WE NEED TO VERIFY OR OBTAIN FURTHER INFORMATION.YOU SHOULD UNDERSTAND THAT THIS REFERRAL FORM DOES NOT ESTABLISHA DOCTOR-PATIENT RELATIONSHIP; YOU MAY BECOME A PATIENT ONCE YOUCOME TO PARTNERS FOR TREATMENT. AT THAT POINT, THIS FORM WILL BECOMEUNDER EIGHTEEN (18) MAY NOT SUBMIT THIS FORM VIA THE INTERNET.PARTNERS CANNOT ABSOLUTELY GUARANTEE THE CONFIDENTIALITY OR SECURITYOF SUCH ELECTRONIC TRANSMISSIONS.Who recommended our services to you?Relative/acquaintance/friendDo you have a preference for one of the following hospitals:Brigham and Women's HospitalMassachusetts General HospitalDana-Farber Cancer Institute (adult cancer services only)Local Address in Boston (if available)Local Telephone: (if available)Clinical Department or Specialty:Anticipated Travel Dates to Boston:Emergency Telephone Number**Patient Services Information**Will you need assistance with the following?Number of guests traveling with youTransportation from Logan Airport to hotel or hospital:Special diet during your hospital stay:*Note: For self-pay patients requiring hospitalization, payment inadvance is required. For some insurers and for embassy cases, we acceptletters of guarantee in place of advance payment. If available, please