Provider Referral Request Form

At Health Connections, Inc. we understand that your time is valuable. For your convenience, we now offer online appointment requests via email. Please fill out the following information and send it to us. We will do our best to honor your request for a specific date and time. Our staff will contact you to confirm appointment availability.

Please note that sending in this request for an appointment is voluntary on your part and does not constitute medical treatment or advice. Your name and contact information will not be used for any purpose other than scheduling an appointment. If you have any questions, please call us at 414-999-1099.

If you prefer to print and fax a referral form, please click here to download the PDF form.