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UW Health SMPH
American Family Children's Hospital
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Request for Clinic Appointment

This form may be used to request an appointment in any UW Health adult or pediatric specialty clinic. The form is for use by referring physicians and/or their staff.

For urgent appointments, please call clinic directly

Thank you for referring your patient to UW Health. Fill out and submit the secure form below to begin the appointment request process. Please notify your patient of this appointment request as we may need to contact the patient directly for information.

A member of our staff will contact you within one or two days with appointment details or request for additional information.

* required fields

Please enter information in each field, do not copy and paste information within this request form.

Patient Information

* First Name:
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Middle Name:
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* Last Name:
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* Gender: Female Male
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* Address:
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* City:
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* State:
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* Zip:
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* Date of Birth (xx/xx/xxxx):
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Parent's Name (if minor):
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Guardian or Representative (if any):
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Interpreter: Yes No
Language:
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Preferred Phone #:
Phone Type: Home Work Cell
Alternative Phone #:
Alternative Phone Type: Home Work Cell
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Additional Contact Instructions
(preferred number,
best time to reach etc.):
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* Name of Insurance
(if no insurance indicate none):
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UWHC Medical Record # or EPIC # (if known)
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Referring Physician Information

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* Referring Provider Name:
Primary Care Physician
(if different than referring):
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* Clinic Name:
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* Clinic Address:
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* City:
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* State:
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* Zip:
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* Telephone Number:
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* Fax Number:
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* Contact Name:
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Contact's Direct Phone Number:
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Appointment Information

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* Reason for Requested Appointment (symptoms and diagnosis):
* Specialty/Specialties Requested:
Specific Physician/NP/PA Requested (if any):
Schedule in First Available Appointment:
Other Scheduling Information/Specific Requests:
* Consult or Referral: Appointment for Consult
Transfer all care for above diagnosis
(Patient will be transferred back when
deemed appropriate)
 
University of Wisconsin Physicians practice at UW Hospital and Clinics, American Family Children's Hospital, and Meriter Hospital. The choice of physicians may determine future location of inpatient admission or surgery.
Hospital Service Provider Preference: UW Hospital & Clinics
American Family Children's Hospital
Meriter Hospital
* What question regarding this patient's medical care would you like the specialist to answer (reason for referral):
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* Pertinent Prior Surgery or Testing for the Above Diagnosis:
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Has the patient previously been seen by a specialist for this problem: Yes No
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If yes, who did s/he see, date of last visit:
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Please fax any records, reports, or test results which are pertinent to this referral to 608-203-2661 or toll free to 888-875-8490.: Records will be faxed
No records will be sent
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