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eConsult submission form

The following form is intended for health care providers to submit an e-Consult for the specialists at Children's Hospital of Wisconsin. This form should not be completed by patients, parents/guardians, family or friends of a patient. Questions should be directed to (414) 266-3456 or

Patient Information
Provider Information
Please note if you select yes, we will be unable to review this case.

e-Consult disclaimer
The service provided through the e-Consult service is different from the diagnostic services typically provided by a physician. The Children's Specialty Group physicians providing this service will not have the benefit of information that would be obtained by examining the patient, obtaining their own history and observing the patient's physical condition. Therefore, the physician may not be aware of facts or information that would affect his or her opinion of the patient's diagnosis. By deciding to engage this service, you acknowledge and agree that you are aware of this limitation and agree to assume the risk of this limitation.

By requesting an e-Consult through this website, you acknowledge and agree that:

  • The advisory opinion and/or recommendation is limited and provisional;
  • The consultation is not intended to replace a full medical evaluation with a physician;
  • The physician(s) performing the e-Consult does not have the benefit provided by a direct physical examination.

By engaging our services, you acknowledge and agree to solely assume the risk of these limitations, you further understand that no warranty or guarantee has been made concerning any particular advisory opinion, result or cure of the patient's condition.

Use of this service does not oblige the provider to refer to Children's Hospital of Wisconsin, Children's Specialty Group, The Medical College of Wisconsin or any affiliated providers.

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If you have further questions please call (414) 266-3456 or e-mail