Referrals

Specialty Clinic Referral Forms

• Airway, Digestive and Voice Center Referral.
• Cardiac Cath Lab.
• Endocrine Clinic.
• Feeding, Swallowing and Nutrition Center.
• GI Motility and Functional Bowel Disorders.
• Neurology Clinic.
• NEW (Nutrition, Exercise and Weight Management) Kids^TM Program.
• Psychiatry and Behavioral Medicine Center.
  Note: Due to special requirements for mental health referrals, the parent must contact the center at (414) 266-2932 once the referral has been faxed to complete the intake and scheduling process. Privacy laws prohibit us from contacting the patient/parent to follow up on an incoming referral.
• Pulmonary Clinic.
• Sleep Center.

Outpatient Order Forms and Consent 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.

• HIV Testing Consent - Includes consent for HIV testing and disclosure of results.
  Note: If ordering the rapid HIV antibody screen you must give the patient/legal guardian the patient education sheet called "Rapid HIV Test." or "Spanish Rapid HIV Test."  Print the patient education sheet by clicking the link then the printer icon. The patient/legal guardian must be given this information prior to signing the consent form for the test.
  (English / Spanish)

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

In order to view the forms and consents, you must have version 4 or higher of Adobe Acrobat Reader installed on your computer.