Medical professionals

Home>
Medical professionals>
Refer a patient>
Refer a patient request an appointment

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.

Patient first name

Patient last name

Patient's date of birth

Parent/guardian's first name

Parent/guardian's last name

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

Parent/guardian's email

Patient's street address

Patient's city

Patient's state

Patient's zip

Referring provider first name

Referring provider last name

Email address for confirmation

Department/specialty referring to

Type of referral Consultation only Consultation/treat Jointly manage care Transfer of care

Clinical question (200 character limit)

Comments

If you don't want to receive health-related emails, please uncheck the box. You can opt-out at any time.

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.

Waukesha parade tragedy

In this section

Medical professionals

Ambulatory referral order

This form is not for urgent health problems, same-day appointment, or appointment cancellations.