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
Patient's Information
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.

To refer a patient, contact Central Scheduling.

(414) 607-5280

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

Request an appointment

Staffed 24 hours a day.

  • Refer a patient
  • Discuss a case
  • Arrange a transport
  • Direct admission

(414) 266-2460

Toll-free: (800) 266-0366