Outpatient Order Forms and Consents

Children's Hospital of Wisconsin offers ancillary services to community physicians. Physicians must complete an Outpatient Order form for each patient and fax it to CHW prior to sending the patient to CHW. Select the appropriate links based on the description offered, a PDF version of the form will be displayed which you may print to your local printer.

In order to use the Outpatient Orders and Consents forms, you must have version 4 or higher of Adobe Acrobat Reader installed on your computer.

Order Forms

Outpatient Diagnostic/Rehab Services Orders - Includes: Cardiology, Neuro-Diagnostic, Pulmonary Function, Rehabilitative Services, Anesthesia and Esophageal pH probe.

Outpatient Laboratory Orders Includes commonly ordered tests of blood, urine, and stool, in addition to common cultures and drug levels.

Outpatient Specialty Laboratory Orders Includes infrequently ordered specialty tests of blood and urine.

Outpatient Radiology Orders -Includes: General Radiology, Fluoroscopy, CT Scan, Nuclear Medicine, PET/CT, MRI/MRA Scans and Ultrasound.

Consent Forms

HIV Testing Consent English - Includes consent for HIV testing and disclosure of results.

HIV Ongoing Monitoring Consent English - Includes consent for HIV monitoring for a specified period of time and the disclosure of those results.

Spanish Consent Forms

HIV Testing Consent Spanish - Includes consent for HIV testing and disclosure of results.  The entire form is written in Spanish.

HIV Ongoing Monitoring Consent Spanish - Includes consent for HIV monitoring for a specified period of time and the disclosure of those results.  The entire form is written in Spanish.