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 health care 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 Froedtert & The Medical College of Wisconsin physician, our staff will be happy to help you find one that meets your needs.
A representative 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.
Your information is secured by a GeoTrust SSL certificate.
* 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] MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day12345678910111213141516171819202122232425262728293031 Year:
* Patient's Gender [Required] Choose OneMaleFemale
City State Zip WIILALAKAZARCACOCTDEDCFLGAHIIDINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWY
*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 Please provide a brief description of why you want to see the doctor.
Thank you for submitting your appointment request.
A representative from the Froedtert & The Medical College of Wisconsin Clinics will call you within one business day to schedule your appointment.
This form is for requesting routine appointments. 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 health care information or any other non-scheduling related requests will not be responded to.
Return to the Online Physician Directory