Please fill out the form below to refer a patient to our Comprehensive Heart Failure Program or to request a second opinion regarding your heart failure diagnosis.

Please indicate if you are a patient or a physician.
Patient's Information
Gender
Date must be entered as MM/DD/YYYY.
VAD
Heart Transplant
Second Opinion
Inotropes
Palliative Care
Referring Physician Information
Diagnosis/Disease Category
Check all that apply.
Requesting Evaluation Therapy for
Check all that apply.
Supporting Documents
If you are faxing the supporting documents, please fax them to 414-805-1080.
Insurance card/information
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
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Face Sheet
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
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Office Notes/H&P
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
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List of Current Medications
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
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Lab Results
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Cardiac Testing Reports
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
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414-777-7700
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Virtual Visits Are Available

Safe and convenient virtual visits by video let you get the care you need via a mobile device, tablet or computer wherever you are. We'll assess your condition and develop a treatment plan right away. To schedule a virtual visit, call 414-777-7700.

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Recognized as High Performing by U.S. News & World Report

Froedtert Hospital, Froedtert Menomonee Falls Hospital and Froedtert West Bend Hospital are recognized by U.S. News & World Report as high performing in heart failure care.

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