Forms

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

*Note: Due to special requirements for mental health referrals, the parent/guardian must contact the center at (414) 266-3339 once the referral has been faxed to complete the intake and scheduling process. You now have the option to obtain the parent/guardian signature (if the patient is age 14 or older) at the time of referral to authorize the Psychiatry Center to communicate with you about the referral. Call the Psychiatry Intake line at (414) 266-3339 with questions.

Outpatient forms

• Outpatient Diagnostic/Rehab Services Orders - Includes Cardiology, Neuro-Diagnostic, Pulmonary Function, Rehabilitative Services, and Anesthesia.
• Outpatient Laboratory Orders - Includes commonly ordered tests of blood, urine, and stool, in addition to common cultures and drug levels.
• Outpatient Imaging (Radiology) Orders - Includes General Radiology, Fluoroscopy, CT Scan, Nuclear Medicine, PET/MRI, MRI/MRA Scans, and Ultrasound.
• pH/Impedance 24 Hour Study Order - Used to order the pH Impedance Study.
• HIV Testing Documentation - Used to document verbal consent for HIV Testing.
• Individualized Education Plan
• 504 Plan Information

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