eConsult submission form

e-Consult 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 csg@chw.org.

Patient Information
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Date of birth
Sex


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Provider Information
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Is a provisional diagnosis known?

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Is this patient case currently in or anticipated to be in litigation? (Please note if you select yes, we will be unable to review this case.)

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