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Ambulatory referral order

If you are a physician or staff requesting an appointment for your patient at a Children's Hospital clinic, use the form below. A member of our Central Scheduling team will call your patient within 1-2 business days to schedule an appointment. This form is not required to refer a patient. It also is not intended to replace Epic ambulatory referral orders.

You also can call our Central Scheduling office Monday - Thursday 7:30 a.m. - 5:30 p.m. and Friday from 7:30 a.m. - 5:30 p.m., at (414) 607-5280 or (877) 607-5280.

This form is not for urgent health problems, same-day appointment, or appointment cancellations.

Items with a red asterisk are required.

Patient's first name

Patient's last name

Patient's date of birth (MM/DD/YYYY)

Parent/guardian's first name

Parent/guardian's last name

Parent/guardian phone number (XXX-XXX-XXXX)

Parent/ guardian email address

Patient's street address

Patient's city

Patient's state

Patient's zip code

Referring provider first name

Referring provider last name

Email address for confirmationPlease note: An email confirmation will be sent to this email address. If you do not want an email confirmation, do not add an email address.

Department/specialty referring to

Type of referral

Consultation only

Consultation/treat

Jointly manage care

Transfer of care

Clinical question (200 character limit)

Comments

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Ambulatory referral order