Orthopedics

This form is the draft standardized eReferral form for Orthopedics. Final design may differ.
Please provide your feedback in the form on the right-hand side

The form is designed to be viewed on a computer.

For more information about specific sections on the form, please click the yellow "Notes" buttons on the left hand side of the page.

This form is dynamic - selecting an option may reveal additional/nested fields

Patient Information

Surname:

First:

DOB:

Gender:

Male

Female

Other

HN:

Mobile #:

Home #:

Business #:

Email:

Address:

* Indicates a required field

[Optional] Additional Patient Information

Sex assigned at birth:

Female

Male

Intersex

Unknown

Pronouns:

He/Him

She/Her

They/Them

Other

Other pronouns:*

Preferred name

Preferred language:

Translator Required

Specify: *

English

French

Other

Best method of contact:

Mobile

Home

Business

Voicemails acceptable

Alternate contact

Alternate Contact Phone #:

Name:*

Relationship:

Is Alternate Contact the appointment booking contact?

Yes

Unsafe contact persons (do not speak with)

Only speak with patient directly

Do not speak with:

Accessibility concerns or disability

Falls Risk

Patient Requires Lift

Wheelchair

Hearing Impaired

Special considerations (e.g. barriers, tips for care delivery, 3rd party insurance, patient requires escort, cognitive issues)

Details of special considerations: *

Send copies of reports to additional providers

Name(s):*

Contact information:*

This is the Primary Care Provider

WSIB Case

Specify WSIB #:

Notes

Overview

This form is intended for referrals to an Orthopedic service
Receivers using this form may remove options from the Problem Area dropdown to align with the services they provide
Formatting and style is intended to be consistent with other provincially standardized forms to reduce cognitive loads
The number of mandatory fields is limited to reduce administrative burdens.

Notes

Patient Information

These fields are auto-populated when referral is initiated from an integrated Electronic Medical Record (EMR) or Hospital Information System (HIS).

Notes

Additional Patient Information

This section is optional for referrers to complete
Referring providers should use their judgement to determine if any of these fields should be completed. Some fields will auto-complete if launched from an integrated EMR or HIS.

Referral Details

Triage Considerations

Requested Priority:*

Routine

Urgent

Reason for urgent triage: *

Second Opinion

Reason for second opinion:

Primary Problem Area *

Problem Area:*

Left or Right?*

Left

Right

Both

Rapid Access Clinic

Initial assessment at the Rapid Access Clinic will be with an Advance Practice Clinician.

Has moderate to severe osteoarthritis on imaging:*

Yes

Primary Care Physicians and Nurse Practitioners referring to the RAC-LBP Program must be trained and registered with the program.

Have you registered with the RAC-LBP Program and have you completed the associated training?*

Yes

If you are not yet registered, click here for more information

Important Note: After completing training, you will need to wait 2-3 days before submitting your first referral in order to get set up with the RAC-LBP Program.

Are emergent RED FLAGS present?

Yes

RED FLAGS:

Possible Cauda Equina Syndrome:

Loss of anal sphincter tone/fecal incontinence;
Saddle anesthesia about anus, perineum, or genitals;
Urinary retention with overflow incontinence.

Progressive neurologic deficit
Significant trauma

STOP

RED FLAGS present - Please refer patient directly to the closest EMERGENCY.

Does one or more of the following conditions apply?

Yes

Initial low back related symptoms <6 weeks post onset;
Constant low back related symptoms >12 months post onset;
<18 years of age;
Unmanaged established chronic multi-site pain disorder;
Unmanaged established narcotic dependency;
Active LBP-related WSIB claim;
Active LBP-related motor vehicle accident claim;
Active LBP-related legal claim; and/or
Pregnant/post-partum patients (<1 year).

STOP

Patient is NOT eligible for the RAC-LBP Program.

Reason(s) For Referral

STOP

Patient is NOT eligible for the RAC-LBP Program.

(Check all that apply) *

Clarify diagnosis

Recommend appropriate imaging

Clarify need for specialist referral

Recommend further treatment

Clarify activity limitations / restrictions

Other

Please specify:*

Back Specific History

Where has the pain / symptoms been the worst?*

Back Dominant

Leg Dominant

Is there a previous history of back problems?*

Yes

Please specify:*

Previous investigations, treatment and/or surgery for the back problems?*

Yes

Please specify:*

Relevant Comorbidities / Comments:

Does the patient have any of the following YELLOW FLAGS?

Yes

YELLOW FLAGS:

Belief that pain is harmful or severely disabling
Fear avoidance behaviour
Low mood and social withdrawal
Expectation that passive treatment rather than active treatment will help

YELLOW FLAGS:

Select all that apply: *

Belief that pain is harmful or severely disabling

Fear avoidance behaviour

Low mood and social withdrawal

Expectation that passive treatment rather than active treatment will help

Notes:

I hereby refer this patient to the RAC-LBP Program and a physician specialist as appropriate.

Diagnostic Imaging Requirements - Ankle

Diagnostic Imaging Requirements - Arm

Diagnostic Imaging Requirements - Clavicle

Diagnostic Imaging Requirements - Elbow

Diagnostic Imaging Requirements - Femur

Diagnostic Imaging Requirements - Foot

Diagnostic Imaging Requirements - Forearm-Radius

Diagnostic Imaging Requirements - Forearm-Ulna

Diagnostic Imaging Requirements - Hand

Diagnostic Imaging Requirements - Hip

Diagnostic Imaging Requirements - Knee

Diagnostic Imaging Requirements - Pelvis

Diagnostic Imaging Requirements - Shoulder

Diagnostic Imaging Requirements - Tibia

Diagnostic Imaging Requirements - Wrist

X-ray required: must be within 6 months of referral.
Avoid advanced imaging (MRI) in arthritic joints.

If no x-ray report current exists for a ganglion cyst, an ultrasound may be sufficient.

If no x-ray report currently exists:

For a ganglion cyst, an ultrasound may be sufficient;
For Carpel Tunnel, an EMG may be sufficient; and
For trigger finger or nodules, no imaging required.

The following x-ray views are recommended: AP pelvis, AP of affected hip and lateral of affected hip.

The following x-ray views are recommended: Lateral, Skyline, Tunnel, Bilateral PA Standing.

If no x-ray report currently exists:

For a ganglion cyst, an ultrasound may be sufficient;
For Carpel Tunnel, an EMG may be sufficient;
For trigger finger or nodules, no imaging required.

Diagnostic Imaging Requirements - Spine

MRI required - must be within 6 months of referral.
Exception: Scoliosis. A scoliosis series x-ray is required. No MRI.

Concern(s) / Indication(s) Triggering Referral - Ankle *

Select all that apply:

Achilles Tendinopathy

Joint Instability

Fracture

Osteoarthritis

Pain NYD

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral - Foot *

Select all that apply:

Bunion

Charcot Foot

Flatfoot / Pes Planus

Fracture

Ganglion Cyst

Metatarsalgia

Osteoarthritis

Pain NYD

Plantar Fasciitis

Toe Deformity

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral - Hand *

Select all that apply:

Dupuytren’s Contracture

Finger Deformity

Flexor Tendon Injury

Fracture

Pain NYD

Osteoarthritis

Trigger Finger

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral *

Select all that apply:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral *

Select all that apply:

Fracture

Hardware Failure / Reassess Arthroplasty

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral *

Select all that apply:

ACL Tear

Cartilage Injury

Knee Malalignment

Loose Bodies

Meniscal Tear

Multi-Ligament Injury

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral - Shoulder *

Select all that apply:

Joint Instability / Subluxation

Fracture

Osteoarthritis

Pain NYD

Rotator Cuff Tear

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral - Spine *

Select all that apply:

Deformity / Scoliosis / Kyphosis

Fracture

Myelopathy

Neurogenic Claudication

Pain NYD - Back

Pain NYD - Neck

Radiculopathy / Sciatica

Other

Specify:*

Concern(s) / Indication(s) Triggering Referral - Wrist *

Select all that apply:

Carpal Tunnel Syndrome

De Quervain’s Tenosynovitis

Fracture

Ganglion Cyst

Osteoarthritis

Pain NYD

Other

Specify:*

Please specify problem area:*

Brief Description of Referral, History, Management, and Investigations *

Cumulative Patient Profile

Please delete any sensitive information you do not intend to share from the CPP

CPP attached separately (if not entered below)

Current Problem List:

Past Medical History:

Current Medications:

Family History:

Allergies:

Notes

Cumulative Patient Profile (CPP)

This section auto-populates when referral is initiated from an integrated Eletronic Medical Record (EMR) or Hospital Information System (HIS)
Selecting “CPP attached separately” will hide this section.

Preferred Surgeon or Location

All patients will be triaged to the shortest wait time unless a preferred surgeon or location is entered.

Preferred surgeon or location

Surgeon:

Please specify either a preferred surgeon or location

Location:

Patient willing to travel for shorter wait time

Other considerations:

Notes

Preferred Consultant or Location

This section will only be displayed for group practices or central intakes

Personal Health Information that is medically relevant has not been disclosed at the request of the patient.

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Referrer's Information

Site Name:

Address:

City:

Province:

Postal Code:

Phone:

Fax:

Billing #:

Professional ID:

Signed:

Role:

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.

Thank you for taking time to review this form.
Please provide your feedback in the form on the right-hand side
Ontario Health & Amplify Care

Notes

Urgency

Referrals are checked off as "Routine" by default
If a referral is marked as urgent, then a "Reason for urgent triage" must be provided to explain why
Note that the receiver will still triage the referral urgency based on the information provided

Notes

Primary Problem Area

Receivers using this form may remove options from the Problem Area dropdown to align with the services they provide
Selection of a Problem Area will change the fields displayed on the form