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Ambulatory Referral Order

If you are a physician or staff requesting an appointment for your patient, use the form below. A member of our scheduling team will call your patient within 1-2 business days to schedule an appointment. This form is not required to refer a patient. It also is not intended to replace Epic ambulatory referral orders.

This form is not for urgent health problems, same-day appointment, or appointment cancellations.

Please fill in this form as completely as possible. Items with an asterisk * are required fields.

Patient Information


Parent/Guardian Information


Referral Information


Please verify you are a human:

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There are 10 nurses in the picture.

And we have many more pediatric primary care providers in Northeast Ohio. You can meet some of them here.
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The five differences are:
– Phone color
– Coat pocket
– Stethoscope earpiece color
– Stethoscope bell dot
– Clipboard paper color

Need help finding a doctor, choosing a location or getting a general question about Akron Children's answered? Call us or fill out the form and we'll help in any way we can.
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The two matching doctors are 9 and 14.

With virtual visits, you can see our pediatric experts from the comfort of home or wherever you are.
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The correct path:
The Correct Path
We offer many ways to get pediatric care all over Northeast Ohio. Use this page to find the right kind of care and the most convenient location for you.