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American Family Children's Hospital
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Request information

Request Information About the Faint and Fall Clinic

UW Health's Faint and Fall Clinic in Madison, Wisconsin draws on the combined expertise of specialists in cardiovascular medicine, geriatrics and neurology.

 

To request more information or set an appointment, complete the form below. Clinic staff will contact you with further information.

 

Please do not submit urgent questions about your medical care through this website. If you are experiencing a life- or limb-threatening emergency, call 911. If your need is urgent, call your clinic for assistance.

 

 

Name

 

Phone Number (including area code)

HomeWork Cell

 

Best Time to Call

 

 

e-mail Address

 

Patient's Physician

 

Physician Practice Location

 

Has the patient had a recent trauma associated with the faint or fall?

 

Does the patient have a family history of sudden cardiac death at a young age or premature heart disease?

 

Which of the following diagnoses has the patient received?