Download Referral - Health Sciences North

NORTH EAST JOINT ASSESSMENT CENTRE
REFERRAL FORM
REFERRAL DATE:
DATE RECEIVED:
DD MM YYYY
DD MM YYYY
Please fax completed referral to your LOCAL North East Joint Assessment Centre (NEJAC):
Fax: 705-495-7577
 NEJAC – North Bay Site
 NEJAC – Sault Ste Marie Site Fax: 705-256-3482
 NEJAC – Sudbury Site
Fax: 705-522-2906
 NEJAC – West Parry Sound Site
Fax: 705-773-4634
 NEJAC – Timmins Site
Fax: 705-360-6695
ASSESSMENT: Your patient will be assessed at the NEJAC closest to their home unless specifically directed.
CONSULT:
When your patient has been determined to be a Surgical candidate they will be given the option to
select a specific surgeon or the Next available surgeon (specific site or NELHIN).
Surgeon Preference (if appropriate):
PATIENT INFORMATION (sticker)
REFERRING PHYSICIAN INFORMATION (sticker)
Name:
Name:
Address:
Address:
Phone:
Phone:
DOB:
DD MM YYYY:
Specialty:
Gender:
 Male
OHIP Billing Number:
 Female
Health Card Number:
Signature:
Alternate Contact Information:
Family Physician Information (if different from above)
Name:
CLINICAL INFORMATION
Joint(s): HIP
 Right
KNEE
 Right
SHOULDER  Right
 Left
 Left
 Left
 Bilateral
 Bilateral
 Bilateral
Level of Pain:
 Mild  Moderate  Severe
Functional Limitation:  Mild  Moderate  Severe
DIAGNOSTIC IMAGING REQUIREMENTS
ATTACHED:
 Yes
Diagnosis:
 Osteoarthritis
 Inflammatory Arthritis
 Impingement syndrome
 Frozen Shoulder
 Rotator cuff tear:
 Revision (Hip/Knee)
 Instability
 Partial thickness
 Full thickness
 OTHER:
 No
Knee:
Bilateral Standing AP, Lateral, Skyline of affected knee(s)
Hip:
AP pelvis, Lateral of affected hip(s)
Is this condition covered under WSIB?  Yes  No
CURRENT MEDICATIONS LIST
Previous THR Patients: above HIP views + AP of Proximal
half of femur (ensure tip of stem visible)
Shoulders X-Ray, Ultrasound, MRI Report (minimum 1
diagnostic imaging report required)
ATTACHED:
NOTE:
 Yes
 No
If not attached please inform patient to bring list to
first NEJAC appointment.
NEJAC USE ONLY
Paper Triage Code:
 A (Appropriate – Direct to surgeon)
Surgeon:
 B (Appropriate: To be seen by APP)
 C (Not Appropriate for NEJAC)
Triaged by:
Reason:
Date:
Legend: APP – Advanced Practice Phsysiotherapist
Form # – N/A
REV 27 AUG 2014
NEJAC – REFERRAL FORM