Medical College of Wisconsin Patient Care

If you prefer to schedule by phone:

Locally:
(414) 805-3666

Toll-free:
(800)272-3666

We're available to answer your call Monday through Friday between
7:30 am and 5 pm CST.

Web Appointment Request

This form is for making 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.

To request an appointment, please complete as much information as possible. If you do not already have a Medical College physician, our staff will be happy to help find one that meets your needs. You may also use the Doctors Search

If you are enrolled in a Health Maintenance Organization (HMO) you must have a primary care physician (PCP.) A referral authorization number from your PCP is needed before we can schedule you for an appointment with a specialist.

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

A representative from Froedtert & Medical College Clinics will call you within one business day to schedule your appointment.

Fields marked with an asterisk (*) are required.

Patient's Name

*First:	*Last:
*Are you the patient? Yes No
Your Name First:	Last:
Your Relationship to Patient
Your Contact Information:
*Daytime Phone, including area code:	Ext. Type
Alternate Phone including area code:	Ext. Type
Email:
Best times to contact you at above number:
Check all that apply: 7:30 am - 10 am CST 10:00 am - 12:00 pm CST 12:00 pm - 2:00 pm CST 2:00 pm - 5:00 pm CST
Patient's Address:
Address
City
State Zip
Patient's Phone:
*Daytime Phone including area code:	Ext. Type Same as above
Alternate Phone including area code:	Ext. Type Same as above
Other Patient Information:
*Gender	Male Female
*Birthdate
Social Security No.
Insurance
Employer
*Reason for Appointment/Symptoms/Diagnosis:

Department or Doctor requested:

To search for a doctor, click here or you may leave blank and we will assist you when we call.
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