back to school care plans

If you would like for us to send a diabetes care plan to your child’s school, you will need to complete the Release of Information. You can complete the form by:

• Printing out the form and bringing it with you to your next appointment (if your child will be seen in the diabetes clinic before school starts)
• Filling out the form electronically (on a computer is easier than phone) and sending it through a MyKidsChart message (instructions for sending a message available here under “Patient forms, instructions and handouts” then “Sending messages” under “MyKidsChart tips sheets”)
• Printing out the form and returning it by:
  • In-person: Drop off at the endocrinology clinic registration desk
  • Fax: 937-641-5878
  • Mail: Attention Endocrinology Clinic

Dayton Children’s Hospital
One Children’s Plaza
Dayton, OH 45404

Please complete all highlighted sections in the form. If you complete electronically, to sign the document click “Fill & Sign” in the right navigation in Adobe PDF viewer, then “Sign” at the top, then follow the prompts to insert your signature(s).

Please keep in mind that it can take up to 2 weeks for care plans to be completed. Once the plan is complete, we will post it to your MyKidsChart account so you can share with your child’s school.

Thank you for working with us in this process!

Sincerely,
Dayton Children’s Diabetes Team