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.

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