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, Audiology, Dental or Ophthalmology. Visit our orders / referrals forms that require signature.

Items with a red asterisk* are required.