Medical professionals

EMS request for information

This form is for Emergency Medical Services (EMS) personal to submit information about pediatric patients they deliver to Children's Wisconsin's Emergency Department/Trauma Center. Our policy allows for two requests per patient by EMS.

Requestor's Information

First name

Last name

E-mail

Phone

Name of service

Training officer/EMS division chief

Patient's Information

Full name

Provider address

Date of birth

Date of service

Type of request Urgent (Follow up within 48 hours) Non-urgent (Follow up within pre-arranged timeframe)

Reason for transfer Trauma Medical

Specific questions or comments

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Note: Please make sure run sheet is available. Fax run sheet to Children's Wisconsin's Emergency Room/Trauma Center (ER/TC) at (414) 266-2496.

If information is needed for Critical Incident Stress Management (CISM) within 48 hours, please call Children's Wisconsin's Transport Office at (414) 266-2470.

Refer a patient

To refer a patient, contact Central Scheduling.

(414) 607-5280

Fax: (414) 607-5288
Toll-free: (877) 607-5280

Request an appointment

Physician consultation line

Staffed 24 hours a day.

Refer a patient
Discuss a case
Arrange a transport
Direct admission

(414) 266-2460

Toll-free: (800) 266-0366