PATIENT INFORMATIONPatient’s Name: ______________________________________q M q F DOB: __________________________________Parent/Guardian Name(s): ______________________________

Home Phone: _________________________________________

Cell Phone:_________________Work Phone _______________

Email address: ________________________________________

Preferred Contact Phone: q Work q Cell q Home

Do you need an interpreter? _____________________________

Patient is in custody of: q Parents q Guardian q CSB Address: ____________________________________________

City:__________________State___________Zip ____________

1st Insurance:__________________ID# ____________________

Precert # __________________________________________

2nd Insurance:__________________ID# ____________________

Precert # __________________________________________

REASON FOR REQUEST Diagnosis Code/Reason for request: __________________________________________________________________________________

Additional relevant diagnostic/clinical information or testing: ________________________________________________________________

Please list any additional mental or physical disabilities: ___________________________________________________________________

Please check: q Diagnose only q Diagnose and treat

Additional clinical documentation is included with this request: q Yes q No (PLEASE include ALL applicable clinical documentation to assist in triaging appointments.)

SERVICES REQUESTED

REQUESTING PROVIDER GROUP:Office name __________________________________________Provider name ________________________________________Office location _________________________________________Office contact person____________________________________Phone ______________________Fax______________________Signature _____________________________________________

Date of Request: ______________________________PLEASE PRINT (ALL INFORMATION IS REQUIRED)

Our goal is to process referrals within two business days. If unable to contact family within one week,

we will notify your office.

**If it is medically necessary for this patient to be seen urgently by a physician,

call the department directly. **

Central Scheduling/Specialty Clinic Notes:

❏ Adolescent Young Adult Medicine Clinic

❏ Airway Clinic❏ Allergy/Immunology Clinic❏ Autism Clinic❏ Burn/Wound Clinic❏ Cardiology Clinic❏ Preventative Cardiology Clinic❏ CARE Clinic❏ Cerebral Palsy Clinic ❏ Children’s Health Clinic❏ Cleft Lip/Cleft Palate❏ Dentistry and Oral Surgery

❏ Developmental Pediatrics Clinic❏ Diabetes Clinic❏ Down Syndrome Clinic❏ Endocrinology Clinic❏ ENT Clinic❏ ENT ­ Advanced Pediatric/ Airway Clinic❏

Gastroenterology Clinic

❏ Genetics Clinic❏ Genetic Counseling Clinic❏ Gynecology Clinic❏ Hematology/Oncology Clinic

❏ High­Risk Infant Nutrition Clinic❏ Immunology Clinic❏ Infectious Disease Clinic❏ Lead Poisioning Clinic❏ Lipid Clinic❏ Liver Clinic ❏ Myelomeningocele Clinic❏ Nephrology/Hypertension Clinic❏ Neurology Clinic❏ Neurosurgery Clinic❏ Nutrition Clinic❏ Opthalmology Clinic

❏ Orthopaedics Clinic❏ Pain Clinic❏ Physical Medicine and Rehabilitation Clinic❏

Plastic Surgery Clinic❏ Psychiatry Clinic❏ Psychology Clinic❏ Pulmonary Clinic ❏ Sleep Clinic❏ Sports Medicine Clinic❏ Surgery/Pediatric Clinic❏ Urology Clinic

❏ Routine 㭸 㭸 ❏ Urgent

RFSS_166214_8/17

REFERRAL FOR SPECIALTY SERVICES Central Scheduling

PH: 937-641-4000 Fax: 937-641-4500 Toll Free Fax: 866-891-6941One Children’s Plaza • Dayton, OH 45404-1815 • childrensdayton.org