(414) 266-2000

Urgent Care & ER

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
Patient's Information

Note: Please make sure run sheet is available. Fax run sheet to Children's Hospital of Wisconsin's Emergency Room/Trauma Center (ER/TC) at (414) 266-2496.

If information is needed for Critical Incident Stress Management (CISM) within 48 hours, please call Children's Hospital of Wisconsin's Transport Office at (414) 266-2470.

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(414) 266-2460

Toll free: (800) 266-0366