Fax referral forms: 937-641-4500, 24 hours
Toll-free fax: 1-866-891-6941
Hours: 7:30 am to 6:00 pm, Monday through Friday
The forms below are interactive so you can type in the information, print and fax to the number indicated on the form.
Please note that practice information is required. This information can be filled out on the top righthand side of the referral form.
- Referral for Specialty Services or use our online submission form!
Please make sure all fields are filled in when using the online submission form. If a field is not applicable to your patient, please type in "N/A".
- Cardiology Testing Lab
- Children's Home Care of Dayton
- Diagnostic Testing Order form
- Genetics Laboratory outpatient order form
- Laboratory - Dayton Children's
- Medical Imaging - Main Campus
- Medical Imaging - Springboro
- Mental Health Resource Connection
- Newborn Follow-up clinic
- Ohio Pediatric Care Alliance
- Outpatient Testing Centers
- Pulmonary Diagnostics
- Rehabilitative Services/ Audiology
- Sleep lab
- Synagis clinic
The guidelines below are intended to assist primary care and emergency providers with the evaluation and treatment of pediatric patients.
All referrals to specialty clinics can now be made online through a single form. Simply fill out the form, noting that each field is required, and submit it. The online submission is available for the following specialty clinics:
Almost Home Unit
Cerebral Palsy Team
Children’s Health Clinic
Cleft Lip/Cleft Palate
Dentistry and Oral Surgery
Diabetes – Outpatient Education
Down Syndrome Clinic
ENT - Advanced Pediatric/Airway
High-Risk Infant Nutrition
Neurology & EEG
Psychology – Clinical Psychology
Psychology – Education Specialist
Skin Infection Clinic
Sleep Center – Clinic
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