Request an Appointment

Use the form below for requesting routine appointments with a health care provider. If this is an emergency, call 911 or go to your local emergency room.

To make an urgent appointment, please call us at either 414-805-3666 or 800-272-3666.

Requests for healthcare information or any other non-scheduling related requests will not be responded to. This form is for appointment requests only.

To request an appointment, please complete as much information as possible. If you do not already have a Medical College of Wisconsin physician, our staff will be happy to help you find one that meets your needs or you may search the online provider directory.

A representative from Froedtert & The Medical College of Wisconsin Clinics will call you within one business day to schedule your appointment. It is important that you provide adequate telephone number(s) and contact information in order for us to reach you.

Fields marked with an asterisk (*) are required.


SSL Certified!Your information is secured by a GeoTrust SSL certificate. Click the GeoTrust logo below to verify site security.

  Patient Information

    * Are you the patient? [Required]
        Yes  No

       If you are not the patient, your name:
      

    * Patient First Name [Required]              * Patient Last Name [Required]
                              

    * Birth Date [Required]
           Year:

    * Patient's Gender [Required]
      

       Patient's Address
      

       City                                                          State            Zip 
                        

  Contact Information

     *Primary Phone (include area code) [Required]
      

      Alternative Phone (include area code)
      

      Best time to contact you at the above phone number
        8 a.m. - 10 a.m. (CST)
        10 a.m. - Noon (CST)
        Noon - 2 p.m. (CST)
        2 p.m. - 5 p.m. (CST)

      Email (your email will only be used to send confirmation of this submission)
     

      Clinic or Provider or Specialty preference (if any)
     
      Note: Search for a doctor or you may leave blank and we will assist you when we call.     

      Insurance Name / Type
     

 

SSL Certificate
webmaster@mcw.edu
© 2014 Medical College of Wisconsin
Page Updated 08/30/2013