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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 within 1-2 business days 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.
Items with a red asterisk* are required.