In this section
Specialty clinic referral forms
Most specialties do not require a referral form, and appointments can be made directly through Central Scheduling. Forms for the specialties that require or recommend a referral form due to the complex nature of their patients are below.
- Ambulatory referral order
- Fetal Concerns Center
- Oncology new patient referral
- New (Nutrition, exercise and weight management) kids™ program
- 504 Plan Information
- HIV Testing Documentation - Used to document verbal consent for HIV Testing.
- Individualized Education Plan
- Outpatient Diagnostic/Rehab Services Orders - Includes Cardiology, Neuro-Diagnostic, Pulmonary Function, Rehabilitative Services, and Anesthesia.
- Outpatient Imaging (Radiology) Orders - Includes General Radiology, Fluoroscopy, CT Scan, Nuclear Medicine, PET/MRI, MRI/MRA Scans, and Ultrasound.
- Outpatient Laboratory Orders - Includes commonly ordered tests of blood, urine, and stool, in addition to common cultures and drug levels.
- pH/Impedance 24 Hour Study Order - Used to order the pH Impedance Study.
- Pre-Op H&P
In order to view the forms and consents, you must have version 4 or higher of Adobe Acrobat Reader installed on your computer.
Refer a patient
To refer a patient, contact Central Scheduling.
Fax: (414) 607-5288
Toll-free: (877) 607-5280
Physician consultation line
Staffed 24 hours a day.
- Refer a patient
- Discuss a case
- Arrange a transport
- Direct admission
Toll-free: (800) 266-0366