Medical professionals

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.

Patient first name

Patient last name

Patient's date of birth

Patient's sex

Parent/guardian's first name

Parent/guardian's last name

Parent/guardian's phone number (XXX-XXX-XXXX)

Patient's street address

Patient's city

Patient's state

Patient's zip

Referring provider first name

Referring provider last name

Referring provider phone number. We will only call you if we have questions regarding this referral.

Email address for confirmation

Department/specialty referring to

diagnosis and ICD – 10 code

Clinical question (200 character limit)

Comments

If you don't want to receive confirmation emails, please uncheck the box.

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

In this section

Medical professionals

Ambulatory referral order

Physician consultation line

(414) 266-2460