Orthopedics
This the eReferral form for Orthopedics.
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:
HN:
Mobile #:
Home #:
Business #:
Email:
Address:
* Indicates a required field
[Optional] Additional Patient Information
Preferred Name:
Sex assigned at birth:
Pronouns:
Other pronouns:*
Preferred language:
Specify language and considerations:*
Best method of contact:
First Contact Name: *
Email (if different than pt):
Phone (if different than pt):
Relationship (incl. SDM):
Is this person an appointment booking contact?*
Second Contact Name:
Email (if different than pt):
Phone (if different than pt):
Relationship (incl. SDM):
Is this person an appointment booking contact?
Do not speak with:
Specify:
Details of special considerations: *
Referral Details
Triage Considerations
Requested Priority:*
Reason for urgent triage: *
Reason for second opinion:
Please describe, including gestational age or estimated delivery date:*
Primary Problem Area
Problem Area (select one option):*
Diagnostic Imaging Requirements - Shoulder
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Arm
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Elbow
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Forearm
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
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 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.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Hand
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
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.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Are emergent RED FLAGS present?*
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.
Rapid Access Clinic
Have you registered with the RAC-LBP Program and have you completed the associated training?*
STOP
Primary Care Physicians and Nurse Practitioners referring to the RAC-LBP Program MUST be trained and registered with the program.
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.
Does one or more of the following conditions apply?*
• 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
Select all that apply: *
Please specify:*
Back Specific History
Where has the pain / symptoms been the worst?*
Is there a previous history of back problems?*
Please specify:*
Previous investigations, treatment and/or surgery for the back problems?*
Please specify:*
Relevant Comorbidities / Comments:
Does the patient have any of the following YELLOW FLAGS?*
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.
Specify Area(s) of Concern
Diagnostic Imaging Requirements - Spine
• MRI required - must be within 6 months of referral.
• Exception: Scoliosis. A scoliosis series x-ray is required. No MRI.
If imaging is not attached, please indicate reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Important Information to Assist Triage
Important Information to Assist Triage
Important Information to Assist Triage
Important Information to Assist Triage
Important Information to Assist Triage
Important Information to Assist Triage
Important Information to Assist Triage
Specify:*
Diagnostic Imaging Requirements - Pelvis
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Rapid Access Clinic
Initial assessment at the Rapid Access Clinic will be with an Advance Practice Clinician.
Has moderate to severe osteoarthritis on x-ray:*
Diagnostic Imaging Requirements - Hip
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Thigh
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Rapid Access Clinic
Initial assessment at the Rapid Access Clinic will be with an Advance Practice Clinician.
Has moderate to severe osteoarthritis on x-ray:*
Diagnostic Imaging Requirements - Knee
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Leg
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Ankle / Hindfoot
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Diagnostic Imaging Requirements - Midfoot / Forefoot
• 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 imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Specify problem areas:*
Specify problem area:*
Diagnostic Imaging Requirements - Other
• X-ray required: must be within 6 months of referral.
• Avoid advanced imaging (MRI) in arthritic joints.
If imaging is not attached, please provide reason: (e.g. pending, specific patient factors, not clinically indicated, etc.):
Concern(s) / Indication(s) Triggering Referral *
Select all that apply:
Specify:*
Clinical Question / Goal(s) of Referral with Relevant History, Exam, Investigations and Management*
Specify WSIB #:
Cumulative Patient Profile
Please delete any sensitive information you do not intend to share from the CPP
Current Problem List:
Past Medical History:
Current Medications:
Family History:
Allergies:
Notes
Cumulative Patient Profile (CPP)
X
Referral Preferences
All patients will be triaged to the shortest wait time unless a preference is entered.
Clinician Name:
Location:
Other considerations:
Notes
Preferred Consultant or Location
X
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Referrer's Information
Site Name:
Address:
City:
Province:
Postal Code:
Phone:
Fax:
Billing #:
Professional ID:
Signed:
Role:
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Ontario Health & Amplify Care
Notes
Overview
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Notes
Patient Information
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Notes
Additional Patient Information
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Notes
Urgency
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Notes
Primary Problem Area
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Notes
Referrer’s Information
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