Make a Referral

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Make a Referral

Central Scheduling

Phone: 937-641-4000
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

Referral Forms

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 Guidelines

The guidelines below are intended to assist primary care and emergency providers with the evaluation and treatment of pediatric patients.

Pediatric Constipation Treatment & Referral Guidelines
Developmental Pediatrics and Mental Health Referral Guide


Online Specialty Clinic Referral Form

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:

Airway Management
Allergy Clinic 
Almost Home Unit
Autism Clinic
Burn/Wound Clinic
Cardiology Consult
CARE Clinic
Cerebral Palsy Team
Children’s Health Clinic
Cleft Lip/Cleft Palate
Dentistry and Oral Surgery
Developmental Pediatrics
Diabetes – Outpatient Education
Down Syndrome Clinic

ENT - Advanced Pediatric/Airway
Genetics Clinic
Genetic Counseling
High-Risk Infant Nutrition
Infectious Disease
Lead Poisoning
Lipid Clinic
Liver Clinic
Metabolic Clinic
Myelomeningocele Team
Neurology only
Neurology & EEG
Nutrition Clinic
Plastic Surgery
Psychology – Clinical Psychology
Psychology – Education Specialist
Skin Infection Clinic
Sleep Center – Clinic


Make a referral

Phone: 937-641-4000
Fax referral forms: 937-641-4500, 24 hours
Toll-free fax: 1-866-891-6941
Hours: 7:30 am to 7:00 pm, Monday through Friday

Download our fax referral form or make a referral online.

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One Children's Plaza - Dayton, Ohio - 45404-1815