Ambulatory referral order

If you are a physician or staff requesting an appointment for your patient at a Children's Wisconsin clinic, use the form below. A member of our Central Scheduling team will call your patient 2-3 business days after to schedule an appointment. This form is not required to refer a patient. It also is not intended to replace Epic ambulatory referral orders.

You also can call our Central Scheduling office Monday - Friday 7 a.m. - 5:30 p.m., at (414) 607-5280 or (877) 607-5280.

This form is NOT for urgent health problems, same-day appointment or appointment cancellations. You can NOT use this form for imaging orders nor referrals to Physical Therapy, Speech Therapy, Occupational Therapy or Dental. Visit our orders / referrals forms that require signature.

Items with a red asterisk* are required.

This is a secure submission. Children's Wisconsin has taken measures to ensure the safety of personal information submitted through the Website. You can safely enter your personal information via our secure server, which encrypts all submitted information.

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