Musculoskeletal Program – Foot/Ankle Referral



Musculoskeletal Program – Foot/Ankle ReferralCornwall Community Hospital ? H?pital Montfort ? Queensway Carleton Hospital The Ottawa Hospital ? Pembroke Regional HospitalRequest For Consultation Fax: 613-721-788932512001*INCOMPLETE REFERRALS WILL BE RETURNED00*INCOMPLETE REFERRALS WILL BE RETURNEDREFERRAL DATE (YYYY/MM/DD):*This referral is not to be used for urgent referrals (e.g. fractures, tendon ruptures)Referring Physician Information – may use stampName: _____________________________________ Specialty: _____________________________________ Address: ____________________________________________________________________________________ Phone: _______________________________________ Fax: __________________________________________ Billing #: ______________________________________ Signature: ______________________________________Family Physician Information (if different)Name: _______________________________________ Phone: _________________________________________Patient Information – may use stickerName: __________________________________________ Address: ______________________________________________________________________________________ Phone: ________________________________________ Date of Birth: ___________________________________ Health Card #: __________________________________ Gender: MaleFemaleAlternate Contact Information:________________________________________________________________________________________________________________________________________________Clinical InformationDiagnosis:Ankle:RightLeftBilateralFoot:RightLeftBilateralAnkle:Ankle Pain NYDAnkle ArthritisAnkle InstabilityTalus OCDAchilles TendinopathyOther (Specify):Foot:Foot Pain NYDMidfoot ArthritisFlatfootHallux ValgusHallux RigidusToe DeformityCharcot FootPlantar FasciitisOther (Specify):Patient-specific considerations:NONECognitive issuesLanguage barrierHearing impairmentVision impairmentOther (Specify):___________________________ Does the patient want surgery?□ yes□ noAppropriate for virtual visit?□ yes□ no Treatment to DateNonePhysiotherapySplinting/FootwearAcupunctureCortisone injectionsMedicationsChiropodist/PodiatristOtherSurgeon PreferenceFirst Available Surgeon□Specific Surgeon: _________________________Diagnostic Imaging Required:This referral MUST be accompanied by the imaging report otherwise IT WILL BE RETURNED. We REQUIRE the following specific X-rays, including WEIGHT-BEARING views, completed within the last 3 months:(please note that “routine” views ARE NOT weight-bearing)Foot: weight-bearing APweight-bearing lateraloblique Ankle: weight-bearing APweight-bearing mortiseweight-bearing lateral (if foot x-rays not done)An MRI/CT scan is NOT RECOMMENDED for initial screening ................
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