Physician Order and Referral / Consult Forms
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.
Referral and Order Forms | Release Forms
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 Walk-in Services
Outpatient Lab / X-ray Order Form Other Referral Forms
ED Referral Form ED Referral GuidelinesInterventional Radiology Referral Form Pre-procedure Physical Exam Form Back to Top
Download Release Forms
Form for Authorization for Use and / or Disclosure of Protected Health Information (58k) Authorization for Use and / or Disclosure of Psychotherapy Notes (51k)Back to Top
