Online Patient Referral Form


Patient Info & Clinical History


Please fill in your details below to make an online referral to the Orthopaedic Rehabilitation Institute.
Your information will be submitted via email.




DATE

URGENT

LOCATION




Referring Physician

.

Patient Information

MaleFemale
MVAWSIBEHCPRIVATEOHIP



DIAGNOSIS

CLINICAL HISTORY

SPECIFIC CLINICAL HISTORY

.



Consultations Required


ORTHOPAEDIC CONSULTATION


CHRONIC PAIN CONSULTATION

INCLUDE

PHYSIATRY CONSULTATION

INCLUDE

RHEUMATOLOGY CONSULTATION

INCLUDE

SPORTS INJURY / MSK MEDICINE

INCLUDE

PROCEDURAL MEDICINE / INJECTION

INCLUDE

PAIN MANAGEMENT PLANNING

INCLUDE

NARCOTIC REDUCTION / PAIN TRANSITION PROGRAM

INCLUDE

RETURN TO PLAY MANAGEMENT / TESTING

INCLUDE

PRE-OPERATIVE PHYSICAL THERAPY ASSESSMENT

INCLUDE

POST-OPERATIVE PHYSICAL THERAPY

INCLUDE

PHYSIO TRAINING SESSION & PROTOCOL DEVELOPMENT

INCLUDE

MULTIDISCIPLINARY REHABILITATION PROGRAM (specify protocol below)

INCLUDE

COMPLEX TRAUMA

INCLUDE

BONE STIMULATOR

INCLUDE

GAME READY

INCLUDE

ORTHOTICS

INCLUDE

BRACE


TWO-WEEK POST OP WOUND CARE CHECK

INCLUDE

OTHER



Treatment Protocol

ACUTE JOINT PAINACUTE SPINE PAINCHRONIC MSK PAINNEUROPATHIC PAIN
FIBROMYALGIA INFUSION THERAPYOTHER:






Medications


Investigations To-Date

X-RaysCT ScansMRI ScansBone ScansRecent Blood Work (including creatinine)Other (see details below)


Specialist Consult Notes

NeurologyOrthopaedicsRehumatologyPhysiatryNeurosurgeryPsychiatryChronic PainOther (see details below)


Acknowledgment

I give my consent to release my personal contact and health information to the Orthopaedic Rehabilitation Institute for the provision of the above-mentioned treatment and services.

CLICK TO ACKNOWLEDGE YOUR CONSENT

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