Hip and Knee Replacement Referral Form

Hip and knee Replacement Referral09884(Rev2019-03)Reason for ReferralWhat is the primary reason you are referring this patient?Type of Problem oPrimaryoRevisionDuration of Symptomso3 - 6 monthso6 - 12 monthsoYearsoOther(specify)Is this a WCB claim? oNooYes, specify claim numberWill you be assigning the patient to the next available surgeon?oNo, specify surgeon name (last, first)oYesPlease print, complete and return this form by fax to the appropriate clinic below. Attach the following with thecompleted form <Relevant medical history/EMR Record <X-ray report -MRI is not required for this referraloX-ray reports attachedKnee: AP weight bearing, lateral of knee with knee flexed, SkylineHip: AP pelvis centered at pubis, AP and lateral of proximal half of affected femurPatients must be on appropriate non-surgical treatment prior to evaluation( medication, physiotherapy, walking aids,shoe inserts).Primary Affected Joint(s) aRightLeftBilateralHipKneeSide APrevious Orthopaedic SurgeriesHas the patient undergone anyprevious orthopaedic surgeries?

Hip and Knee Replacement Referral 09884(Rev2017-03) Reason for Referral What is the primary reason you are referring this patient? Type of Problem

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  Form, Referral, Knee, Replacement, Knee replacement, Knee replacement referral form

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