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Orthopedic Assessment Clinic PRIMARY HIP AND KNEE 2026

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The document is a referral form for orthopedic assessments specifically for primary hip and knee arthroplasty. It includes options for selecting a surgeon or self-management, details on the patient's condition related to arthritis, and requires additional patient information. The form emphasizes the need for current x-rays and outlines the process for submitting referrals.

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Click ‘Get Form’ to open it in the editor.
Begin by selecting one of the three referral options. Choose either the next available surgeon within a specific zone, a specific surgeon, or self-management only.
Indicate the affected joints by checking the appropriate boxes for left hip, right hip, left knee, or right knee.
Provide additional patient information regarding arthritis symptoms and previous treatments. Check 'Yes' or 'No' as applicable.
Fill in any other relevant medical conditions that may affect surgery eligibility and provide details about medications and allergies in the space provided.
Complete the referral source section by printing your name, entering your CPSNS number, signing, and dating the form.
Ensure all required fields are filled out accurately before submitting to avoid delays in processing.

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2018	4.8 Satisfied (20 Votes)

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