Get Hip Referral Form

Filling out the Hip Referral Form online is an essential step in ensuring a smooth referral process for hip and knee replacement assessments. This guide will provide you with clear, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the client demographics. Fill in the patient’s last name, first name, street address, city, postal code, home phone, alternate phone, and personal health number (PHN) in the designated fields. Indicate the patient's gender and date of birth in the specified format.
3. For the referring physician section, provide the name, phone, and fax number of the referring physician. If a family physician differs from the referring physician, fill in their details as well.
4. In the reason for referral section, identify the affected joint(s) by marking the relevant options (right or left for hip and knee) and specify the duration of symptoms (weeks, months, years, or unknown). Indicate the referral request type (surgical assessment, urgent referral, conservative treatment, second opinion, or revision) and provide any necessary details.
5. Assign the patient to the next available surgeon by marking 'yes' or 'no.' If a specific surgeon is requested, provide their last name.
6. Complete the x-ray requirements section by indicating whether the required x-ray reports for the knee and hip are attached. Specify the details if reports are completed.
7. In the special requirements section, indicate any cognitive or sensory impairments and provide contact information as needed. List any activity limitations and language needs.
8. Proceed to the medical assessment section. Record any existing medical conditions, previous surgeries within the last ten years, allergies, and current medications. It's important to be thorough and clear.
9. Document any non-surgical treatments attempted and their results. Ensure you provide details for each treatment attempted.
10. Certify that the assessment has been completed in the past 60 days by signing and dating in the designated area.
11. Finally, review all entries for accuracy. Save changes, download, print, or share the form as needed.

Complete your Hip Referral Form online today for a seamless referral process.