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.


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


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Finding the latest trusted child health and safety information doesn't have to be hard. Pediatric Link, Dayton Children's e-newsletter offers timely and up-to-date information for health care professionals from the experts you trust at Dayton Children's.  Sign up

Upcoming Events

Preble County YMCA fun family event

Free family event for parents of children birth to 5 years old

Pre-ordering now available!! Get your special edition shortbread puzzle piece cookies from Panera Bread! Cookies will be sold in stores April 13th to 19th. 100% of proceeds will benefit Dayton Childrenís Hospital newly launched autism diagnostic center.

View full event calendarView full event calendar

The Right Experts

Just right for all kids


The Children's Medical Center of Dayton Dayton Children's
The Right Care for the Right Reasons

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