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
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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256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
Face Sheet
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256 MB limit.
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Office Notes/H&P
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256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
List of Current Medications
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256 MB limit.
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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.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
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.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
Unlimited number of files can be uploaded to this field.
256 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, jpg, jpeg.
Appointments
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 as high performing in heart failure care.

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