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HIP & KNEE RAPID ACCESS CLINIC REFERRAL PROCESSREFERRAL PROCESS

  • Download the common referral form HERE
  • Complete the form in full (Note: only completed referrals will be accepted)
  • Fax the form and necessary reports to 1-833-230-6623 (toll free number)

REFERRAL CRITERIA

INCLUSION CRITERIA

EXCLUSION CRITERIA

      Moderate to severe hip and knee arthritis

      Patient MUST be 18 years or older

      Urgent referrals characterized by:

o   Prior arthroplasty with peri-prosthetic fracture, infection, recurrent dislocation

o   An immediate threat to role and independence, potentially requiring hospitalization within 4 weeks


 

 

 

 

 

 

 

MANDATORY INFORMATION

  • Preferred RAC Options - not mandatory however, if not indicated will be processed to closest location to patient's residence
  • Patient Information
    • Full Name
    • Date of Birth
    • Gender
    • Health Card Number
    • Complete Address
    • Contact Information
  • Referring Provider Information
    • Full Name
    • Billing Number
    • Practice Address
    • Phone & Fax Number
    • Signature
  • Family Physician Information (if different than referring)
    • Full Name
    • Phone & Fax Number
  • Reason for Referral
    • Indicate which area and side (Left or Right, Hip or Knee)
  • Diagnosis
    • At least one must be selected
  • X-ray Report (MRIs are not appropriate) done within the last 3 months

Mandatory Views:

  • Hip:  AP pelvis, AP and lateral of affected hip
  • Knee: AP weight bearing bilateral knees, lateral of knee flexed at 30º bilateral knees, skyline view bilateral knees, PA standing flexion

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