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 - Friday

Dayton Children's is available to assist referring providers and their patients with an array of services. You may refer patients to the hospital, to a particular service or to an individual specialist for consultation, diagnosis or treatment.

3 easy ways to make a referral

  1. Online specialty clinic referral-For specialty clinics you can use our direct online referral form. 
  2. Fillable and printable PDFs- Please search through our services below to download the appropriate referral form. The PDF forms below are fillable 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.
  3. Order customizable referral forms- You can order customizable forms for your office once and order time and time again.  The forms will be delivered to your office for free.


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