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.


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