NORTH EAST HIP AND KNEE REPLACEMENT PROGRAM REFERRAL FORM REFERRAL DATE: YYYY MM DD DATE RECEIVED: YYYY MM DD Please fax completed referral to your LOCAL North East Joint Assessment Centre (NEJAC):.
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How to fill out the Nejac Sudbury Referral Form online
Filling out the Nejac Sudbury Referral Form online is an essential step in the process of referring a patient for assessment at the NEJAC clinics. This guide provides clear instructions on how to complete each section of the form accurately and efficiently.
Follow the steps to complete the referral form successfully.
- Press the ‘Get Form’ button to access the referral form and open it in your preferred document editor.
- Enter the referral date in the format YYYY MM DD. This date is crucial for tracking the referral process.
- Indicate the date received, also in the format YYYY MM DD, ensuring the referral is properly documented.
- Select the appropriate NEJAC site by checking the corresponding box: North Bay, Sault Ste Marie, Sudbury, or West Parry Sound.
- Complete the patient information section, including the patient’s name, address, telephone number, date of birth, and health card number. You may also use a sticker for this information.
- In the clinical information section, specify the joints involved (hip, knee) and the diagnosis (osteoarthritis, inflammatory arthritis, or other). Indicate the type of procedure being referred: opinion requested, primary joint replacement, or revision joint replacement.
- Assess and document the patient’s level of pain by selecting mild, moderate, or severe, as well as their functional limitation.
- Complete the referring physician information, ensuring to include name, specialty, address, and phone number.
- Attach the X-ray report if available, checking the box accordingly, and ensure the correct X-ray requirements are met. If unattached, inform the patient to bring it to their appointment.
- List current medications and provide your OHIP billing number in the designated fields.
- Sign the form before submission and confirm the attachment of any supporting documents.
- Once all sections are completed, save changes, download, print, or share the form as required.
Complete your referral document online for efficient processing.
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