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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

      Patients MUST be 18 years of age or older

      Moderate to Severe Hip and Knee Arthritis

         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 done within the last 3 months
*MRIs ARE NOT APPROPRIATE*

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

Click HERE to review the guidelines to support you in determining the appropriate imaging for hip and knee osteoarthritis.

 

FOR MORE INFORMATION ON THIS INITIATIVE GO TO:

Mississauga Halton LHIN

MINISTRY OF HEALTH AND LONG-TERM CARE

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