Please fill out the form below to set up an evaluation for cochlear implants For your convenience, you can fill all of this out online and submit the form here. The form allows you to upload your records and the release forms below. 

We will need your medical records so that we have a complete picture of your health history. Additionally, we need to provide your medical information to our cochlear implant manufacturers for your treatment.

You can download the two release forms here. Fill in the fields with the red arrows and sign the forms. 

Contact Information

Who should we contact to schedule the appointment?

Medical History

Have you worked with an ear, nose and throat (ENT) physician or an audiologist?
ENT Physician Contact Information
Audiologist Contact Information
Do you have a history of any of the following?
Include in "Other"
Do you have tinnitus (ringing in your ears or head)?
Do you currently experience dizziness or imbalance?

Hearing Loss History

Which of your ears has hearing loss?
Was the onset of your hearing loss in your right ear sudden or did it progress over time?
Possible Causes of Hearing Loss in Right Ear
Was the onset of your hearing loss in your left ear sudden or did it progress over time?
Possible Causes of Hearing Loss in Left Ear
Have you tried hearing aids?
In which ear(s) do/did you wear hearing aids?

Supporting Documents

We will need your medical records so that we have a complete picture of your health history. Additionally, we need to provide your medical information to our cochlear implant manufacturers for your treatment.

You can download the two release forms here. Fill in the fields with the red arrows and sign the forms. 

You can upload, fax or mail the forms. We do not recommend sending your protected health information (PHI) via email.

Are some of your records available via an Epic/Care Everywhere Record?
How would you like to provide your documents?

You or your doctor's office can send your records via fax or mail.

Fax: 414-955-0075
Mailing address:
Department of Otolaryngology
Attn: Audiology
9200 W. Wisconsin Ave.
Milwaukee, WI 53226

Please upload any outside records specifically related to your history of tinnitus, including hearing tests and any pertinent medical office notes.

One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button.
One file only.
256 MB limit.
Allowed types: gif jpg png txt pdf doc docx ppt pptx.
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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Froedtert Hospital is nationally ranked by U.S. News & World Report in three adult specialties. Froedtert Hospital is also recognized as high performing in four adult specialties and 22 procedures and conditions, including ear, nose and throat.

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