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
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Face Sheet
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Office Notes/H&P
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List of Current Medications
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Lab Results
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Cardiac Testing Reports
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256 MB limit.
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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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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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Rated as High Performing by U.S. News & World Report

Froedtert Hospital is nationally ranked by U.S. News & World Report in three specialties. Froedtert Hospital is also rated as high performing in four adult specialties and 22 procedures and conditions, including cardiology, heart and vascular surgery and heart failure.

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