Physician Services

Physician Order and Referral / Consult Forms

Related Services
Call to Refer Your Patients Download Pediatric Clinical Practice Guidelines
New Fax Number for Referrals
Please fax all referrals and order forms (EXCEPT oupatient lab forms intended for walk-in procedures) to our new fax number at 513-803-1111 or toll free at 866-877-8905.

The staff at Cincinnati Children's Hospital Medical Center believes that building collaborative relationships with primary care physicians helps achieve the best outcomes when treating patients.

One call to our Physician Priority Link hotline will tell you everything you need to know to refer a patient to Cincinnati Children's. And, you can download any form you need right here.

Referral / Consult Form Process

Test and procedure referral forms are required by Cincinnati Children's to schedule various procedures. These forms must be completed and faxed to the Cincinnati Children's Scheduling Center as indicated on each form.

Download Order and Referral / Consult Forms

All referral / consult forms are provided in .pdf format.

You must have Adobe Acrobat Reader installed on your computer to read these forms. You can download Adobe Acrobat" Reader at Adobe's Web site by selecting the version appropriate for your type of computer.

Scheduled Services

• Specialty Services Referral Form
• Radiology Referral Form (includes both Radiology and Nuclear Medicine)
• Diagnostic Testing Referral Form  (includes EKG, ECHO, EEG, EMG, PFT, DXA Scan, GTT and Sweat Chloride)
• OT / PT / Speech Referral Form
• Fetal ECHO and Consult Form

Walk-in Services

• Outpatient Lab /  X-ray Order Form 

Synagis® Home Care Services

• Synagis® Physician Order Form
• Synagis® Statement of Necessity Form

Other Referral Forms

• ED Referral Form
• ED Referral Guidelines
• Interventional Radiology Referral Form 
• Pre-procedure Physical Exam Form
• NCA Follow-Up Referral Form

Download Release Forms

• Form for Authorization for Use and / or Disclosure of Protected Health Information
• Authorization for Use and / or Disclosure of Psychotherapy Notes

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