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

Dayton Children's Hospital is dedicated to working closely with community providers to offer the highest quality care for infants, children and adolescents.

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.

How to make a referral 

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. For specialty clinics you can also use our direct online referral form. 

Please note that practice information is required. This information can be filled out on the top righthand side of the referral form.

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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