Please fill out the following form to refer a patient to our Comprehensive Heart Failure Program or to request a second opinion regarding your heart failure diagnosis. You may also call 414-805-6400 to speak with a member of our intake team.

If you speak another language, assistance services, free of charge, are available to you. Call: 414-805-3000 (TTY: 1-800-947-3529).

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.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
Face Sheet
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.
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.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
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.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
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.
CAPTCHA

By clicking “next page” or “submit,” you agree to the processing and storage of your information in accordance with our Website Privacy Policy. While we take reasonable precautions to protect your data, please be aware that no internet transmission is completely secure. Your form data will not be delivered via e-mail or shared with unaffiliated third parties and will be removed from our website database after 90 days.

Appointments
414-777-7700
Request Appointment
Virtual Visits Available
View Specialists Treatment Locations Contact Us

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.

Learn More

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

U.S. News & World Report rated Froedtert Hospital as high performing in seven adult specialties and 21 procedures and conditions, including heart failure care.

More to Explore