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.

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.