Staff Information


Please indicate if you are a patient or a physician.
Patient's Information
Patient Name
Patient Contact Information
Date must be entered as MM/DD/YYYY.
Is the patient on oxygen?
Diagnosis/Disease Category
Check all that apply.

Referring Physician Information
Referring Physician Name
Referring Physician Contact

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.
PFT Results
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.
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.
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
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.
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.
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.
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