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:

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

Referral Details

Triage Considerations

Requested Priority:*

Routine

Urgent

Reason for urgent triage: *

Second Opinion

Reason for second opinion:

Primary Problem Area *

PLEASE NOTE

At this time you cannot refer a patient for two problem areas within a single referral. If you require the submission of more than one problem area, please submit multiple referrals.

Problem Area:*

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:

Fracture

Joint Instability / Subluxation

Osteoarthritis

Pain NYD

Rotator Cuff / Impingement

Other

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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

De Quervain’s Tenosynovitis

Fracture

Carpal Tunnel Syndrome

Ganglion Cyst

Osteoarthritis

Pain NYD

Other

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:

Dupuytren’s Contracture

Finger Deformity

Flexor Tendon Injury

Fracture

Pain NYD

Osteoarthritis

Trigger Finger

Other

Specify:*

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.

Rapid Access Clinic

Refer to Spine RAC Low Back Pain Program (referrers must be registered with the program)

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

Yes

STOP

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

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.

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

Select 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:

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

• 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 - 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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:*

Yes

Diagnostic Imaging Requirements - Hip

• X-ray required: must be within 6 months of referral.

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

• 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:

Fracture

Inflammatory Arthritis

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:*

Yes

Diagnostic Imaging Requirements - Knee

• X-ray required: must be within 6 months of referral.

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

• 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:

ACL Tear

Cartilage Injury

Inflammatory Arthritis

Knee Malalignment

Loose Bodies

Meniscal Tear

Multi-Ligament Injury

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

Fracture

Osteoarthritis

Pain NYD

Post-traumatic arthritis

Other

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:

Achilles Tendinopathy

Joint Instability

Fracture

Osteoarthritis

Pain NYD

Other

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:

Bunion

Charcot Foot

Flatfoot / Pes Planus

Fracture

Ganglion Cyst

Metatarsalgia

Osteoarthritis

Pain NYD

Plantar Fasciitis

Toe Deformity

Other

Specify:*

Please specify:*

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

WSIB Case

Specify WSIB #:

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:

Thank you for taking time to review this form.
Ontario Health & Amplify Care

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.

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

Notes

Referrer’s Information

Will automatically populate with the referring provider’s information.