EMS request for information

This form is for Emergency Medical Services (EMS) personal to submit information about pediatric patients they deliver to Children's Hospital of Wisconsin's Emergency Department/Trauma Center. Our policy allows for two requests per patient by EMS.

Fill in the following information:

Requestor's Information:
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Patient's Information:
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Date of Birth (MM/DD/YYYY):
Date of Service (MM/DD/YYYY):
Reason for Transfer:


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Type of Request:


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