Appointment Request Form
Let us know how we can help you!
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Employer
Please indicate if your employer participates in our Direct to Employer Program.
Is this appointment related to Workers' Compensation?
Yes
No
What would you like to be seen for?
Back, Neck and Spine
Elbow
Shoulder
Knee
Hip
Hand and Wrist
Physical Therapy
Durable Medical Equipment
Foot and Ankle
Baseline Concussion Testing
Other
Please select the physician you are requesting to see.
Please Select
First Available Specialist
Laith Al-Shihabi, MD
Matt Bong, MD
Lily Bogunovic, MD
Jeff Coppage, MD
Derek Damrow, MD
William Davies, MD
Jon Englund, MD
James Foley, MD
Dan Holub, MD
Paul Johnson, MD
Korey Kasper, MD
Mick Kelly, MD
Christopher Kilian, MD
Mitchell Klement, MD
Josh Labott, MD
David Merkow, MD
Michael Nolte, MD
Rick F. Papandrea, MD
Scott Schneider, MD
Ryan Stefanczyk, MD
Samuel Steiner, MD
Andrew Valiquette, MD
Tom Viehe, MD
Andrew N. Vo, MD
Nick Wilcox, MD
Robert Zoeller, MD
Hongsheng Zhu, MD, Ph.D
Please select the location you are requesting to be seen at.
Please Select
Pewaukee
Johnson Creek
Brookfield
Mukwonago
New Berlin (Therapy appt only)
Germantown (Therapy appt only)
Oconomowoc (Therapy appt only)
Patient Type
New Patient (You are new to Orthopaedic Associates of Wisconsin, or it has been more than 3 years since your last visit)
Existing Patient (You have seen an Orthopaedic Associates of Wisconsin physician within the past 3 years)
Additional Comments
Would you like to be notified about promotional services?
Yes
No
Other
How did you hear about us?
*
Please Select
Billboard
Community Sponsorship
ER/Urgent Care
Family/Friend Referral
Google/Internet Ad
Insurance Website
Physician Referral
Previous Patient
Radio
Social Media
TV
Other
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