Transplant Staff Information Please indicate if you are a patient or a physician. I am a physician referring a patient. I am a patient looking for a second opinion. Patient's Information Patient Name First Middle Last Patient Contact Information E-Mail Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Patient Phone Date of Birth Date must be entered as MM/DD/YYYY. Is the patient on oxygen? Yes No What amount of oxygen does the patient receive? Specific Diagnosis Diagnosis/Disease Category Idiopathic Pulmonary Fibrosis COPD Cystic Fibrosis Pulmonary Arterial Hypertension Sarcoidosis LCH LAM Other… Enter other… Check all that apply. Referring Physician Information Referring Physician Name First Middle Last Suffix Degree Referring Physician Clinic Referring Physician Contact E-mail Phone Physician Notes Summary Primary Care Physician Supporting Documents If you are faxing the supporting documents, please fax them to 414-805-1080. Insurance card/information Upload Fax Upload insurance card/information Upload 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 Upload Fax Epic/Care Everywhere Record Upload face sheet Upload 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 Upload Fax Epic/Care Everywhere Record Upload office notes/H&P Upload 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 Upload Fax Epic/Care Everywhere Record Upload list of current medications Upload 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 Upload Fax Epic/Care Everywhere Record Upload lab results Upload 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. Upload lab results 2 Upload 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. Upload lab results 3 Upload 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. PFT Results Upload Fax Epic/Care Everywhere Record Upload PFT Results 1 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Upload PFT Results 2 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Upload PFT Results 3 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. CXR and CT Reports Upload Fax Epic/Care Everywhere Record Upload CXR and CT Reports 1 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Upload CXR and CT Reports 2 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. Upload CXR and CT Reports 3 Upload One file only.256 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. There will be a slight delay while your file is scanned for potential viruses. Please do not refresh or click the back button. CAPTCHA Submit Leave this field blank Appointments 414-777-7700 Request Appointment View Specialists Treatment Locations Contact Us Services Lung Transplant Referral and Second Opinion Form What Lung Transplant Patients Can Expect Lung Transplant Surgeons, Pulmonologists