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
Dermatology
Developmental Pediatrics
Diabetes
Diabetes – Outpatient Education
Down Syndrome Clinic
Endocrinology
ENT

ENT - Advanced Pediatric/Airway
Gastroenterology
Genetics Clinic
Genetic Counseling
Gynecology
Hematology/Oncology
High-Risk Infant Nutrition
Infectious Disease
Lead Poisoning
Lipid Clinic
Liver Clinic
Metabolic Clinic
Myelomeningocele Team
Nephrology/Hypertension
Neurology only
Neurology & EEG
Neurosurgery
Nutrition Clinic
Ophthalmology
Orthopedics
Pain
Plastic Surgery
Psychology – Clinical Psychology
Psychology – Education Specialist
Pulmonary
Skin Infection Clinic
Sleep Center – Clinic
Surgery/Pediatric
Urology

 

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Just right for all kids

Accreditations

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
937-641-3000
www.childrensdayton.org