KidsCare Link
Physician & Office Staff Registration Form - For New Users

Thank you for your interest in the Dayton Children's KidsCare Link. Please submit the form below to begin your registration process. You will receive your username and password via U.S. mail. For any technical issues, you may contact our Help Desk at (937) 641-5293.

Please note: Items with an asterisk (*) are required.

Is this a request for a Physician or for a Delegate?

Requestor Type:
Access Information

Application Requested:

Physician Information

*First Name:

Middle Initial:

*Last Name:

*Email address:


Clinic Location Information

*Office Name:

*Address:

*City:

*State:

*Zip Code:

*Office Phone:

Fax:
 
Select Submit when you have completed all required fields.