Request an Appointment | Mass. Eye and Ear

Please use this form only if you are a new patient. After you submit your request, our scheduling staff will contact you to schedule your appointment. To request an appointment by telephone during office hours, Monday-Friday, 7:00 am to 6:00 pm, please call:

Ophthalmology (eye): 617-573-3202
Otolaryngology (ear, nose, throat, head and neck): 617-573-3954

This form takes approximately 5 minutes to complete.

PATIENT INFORMATION

First name *This field is required.

Last name *This field is required.

Date of birth *This field is required.

Is this a pediatric patient? *

Please select an answer.

Phone *This field is required.

Email *Please enter a valid email address.

Best time to call

Morning
Afternoon
Evening

Address line 1 *This field is required.

Address line 2

City *Please enter a valid city.

State *Please enter a valid state.

Zip *Please enter a valid zip.

Please provide insurance plan, if known Please enter a valid insurance plan.

ABOUT YOUR APPOINTMENT

Have you been referred by another physician? *

Please select an answer.

Provider name *This field is required.

DepartmentDepartment *

This field is required.

Sub-DepartmentSub Department

Please provide any other additional details about your request

REQUESTOR INFORMATION

Are you the patient? *

This field is required.

First name *This field is required.

Last name *This field is required.

Relationship to patient

Phone *This field is required.

Should we contact you or the patient to make the appointment? *

Me
Patient

Please select an answer.

If you are an established patient at Mass. Eye and Ear, please contact your provider directly to request an appointment.

Search our provider directory to find your provider’s contact information.

For additional help finding a provider, please feel free to call our scheduling/registration center directly:

Ophthalmology (eye): 617-573-3202
Otolaryngology (ear, nose, throat, head and neck): 617-573-3954

You may also use or enroll in Patient Gateway to manage your appointments and other non-urgent health care needs.

Please fill out the form below in English to request an appointment with a Mass. Eye and Ear specialist. One of our patient liaisons will follow up with you within 1-2 business days. We do not recommend making travel plans until you receive a confirmed appointment with a scheduled date and time. If you have any questions, please contact us.

International Office
243 Charles Street
Boston, Massachusetts 02114 USA
Phone: 617-573-4416
Fax: 617-573-6348
Email: international@meei.harvard.edu

This form takes approximately 3 minutes to complete.

PATIENT INFORMATION

First name *This field is required.

Last name *This field is required.

Date of birth *This field is required.

Gender *

Male
Female

Please select an answer.

Is this a pediatric patient? *

Please select an answer.

Reason for visit *This field is required.

ABOUT YOUR APPOINTMENT

Boston/local temporary address (hotel, residence, etc.)

Dates and times expected to be in the Boston area

Will you need an interpreter during your visit to Mass. Eye and Ear?

How do you plan to pay for your care?

Yourself
Commercial

CONTACT INFORMATION

Email *Please enter a valid email address.

Phone *This field is required.

Permanent/international address line 1 *This field is required.

Address line 2

City *Please enter a valid city.

Province/Region

Country *Please enter a valid country.