Get Wrha Central Intake Form For Hip & Knee Replacement Surgery

Filling out the WRHA Central Intake Form for Hip & Knee Replacement Surgery online is an essential step for individuals seeking referral for surgical treatment. This guide will provide you with clear instructions on how to complete each section of the form effectively.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the first section titled 'Consultation Requested from' and select only one option. This will determine how the referral will be processed.
3. Proceed to the 'Patient Demographics' section. Clearly fill in the patient’s last name, first name, gender, date of birth, and health insurance numbers. Ensure clarity for contact information.
4. In the 'Support Person' section, provide the name and telephone number of the individual who will be supporting the patient.
5. Complete the 'Referring Physician Information' section. Include relevant details about the referring physician and family physician, if applicable.
6. In 'Reason for Referral', indicate the joints involved (hip or knee) and whether the condition is right, left, or bilateral, providing necessary descriptions.
7. If applicable, provide information regarding any previous joint replacements including when they were inserted and which hospital performed the procedure.
8. Fill out the 'Medical Information' section with the patient's height, weight, smoking status, and whether non-operative management has been attempted.
9. Indicate if any medical conditions that may delay surgery have been addressed, selecting 'Yes' or 'No'.
10. List any relevant medical history, medications, and allergies in the space provided or attach an additional document if needed.
11. Finally, the referring physician should sign and date the form to validate the referral.
12. After completing the form, review all entered information for accuracy. Save any changes made, download, print, or share the completed form as necessary.

Complete the WRHA Central Intake Form online to start your journey towards hip or knee replacement surgery.