SAMLER (Shoulder, Elbow, Knee)

Spine: please refer to Neurosurgery Hand: please refer to Plastic Surgery

(Subspecialty Interests)

RAPID ORTHOPEDIC CONSULTATION CLINIC (ROCC)

Body Part

Foot / Ankle

Shoulder / Arm

DiagnosisArthritisFractureSoft Tissue InjuryOther

Orthopedic SurgeonBAGGOO (Knee, Foot, Ankle)JANDO (Hip, Knee)

SIDKY (Hip, Knee)ZARKADAS (Shoulder, Elbow, Knee)

X-Ray RequirementPlease attach the requested X-ray reports.

Hand & Wrist (AP and Lateral)

Imaging LocationLions Gate HospitalNorth Shore Medical ImagingSquamish General HospitalOther

Other Medical ImagingMRIUltrasound

We will contact the patient directly for an appointment

PANAGIOTOPOULOS (Hip, Knee)

213 & 214 - 145 West 15th Street • North Vancouver • BC • V7M 1R9

Date

Patient Information

PHN

Urgent Referrals

FIRST AVAILABLE

Date of Birth

Phone #

Gender

Referring Physician Information

MSP #

Has this patient been referred before?

Name of Previous Orthopedic Surgeon

Female Male

dd / mm / yyyy

dd / mm / yyyy

Name Last, FirstLast, First

Yes No

Reason for Referral

History of Present Illness

Expedited Care

YES, I would like expedited care for my patient. The initial consultation may involve a screening physician.

NO, my patient will wait for the requested Orthopedic Surgeon

This referral CANNOT be properly triaged without X-ray reports unless exceptional circumstances are indicated.

McCONKEY (Shoulder, Knee)

Please attach past medical / surgical history, medication list and allergies as required.

PMSOTel: 604-980-0504 • Fax: 604-980-0531

Name

Hip / PelvisKnee / Leg

WristElbow / Forearm

Foot (Standing AP, Lateral, Oblique)Ankle (Standing AP, Lateral, Oblique)

Knee (Standing AP both knees, Lateral, Skyline)Hip (Standing AP Pelvis, True Lateral)

Shoulder (AP, Lateral, Axillary)Elbow (AP and Lateral)

CTNuclear Medicine

Whistler Health Care CentreSechelt Hospital

PACIFIC ORTHOPEDICS AND SPORTS MEDICINE

For urgent assessments, please contact the surgeon on-call directly or via the LGH switchboard at 604-988-3131.

North Shore