Health Connections, Inc.
  • Home
  • Events
  • Wakanda Wellness Week 2024
  • Colorectal Cancer Awareness
  • Donate
  • Media
  • The COVID Division
  • Contact

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.
Submit

Health Connections, Inc.
Make a Donation to Support Our Work


HOURS

M-F  10am - 4pm
Sat  *Call to Inquire 

TELEPHONE

414-999-1099

ADDRESS

4655 N. Port Washington Road, Suite 300 | Glendale, WI 53212
Copyright © 2025 Health Connections, Inc.

ANOTHER WEMERGE MEDIA DESIGN
  • Home
  • Events
  • Wakanda Wellness Week 2024
  • Colorectal Cancer Awareness
  • Donate
  • Media
  • The COVID Division
  • Contact