Required fields are marked with asterisks (*)

Fracture Clinic Referral Form

Please complete the form below.

Patient Name

Date of Birth

Patient's Identified Gender

Health Card Number

Telephone Number

Alternate Contact Number

Please confirm that the patient’s phone number is correct.

All referrals must be discussed with On Call Orthopaedic Surgeon through Locating (905) 576-8711 x 33200.

Referring Physician

Referring Physician's Contact Number

Date

Diagnosis

Date of Injury

Case information and follow up instructions

Follow up information

Follow up in On Call Orthopeadic Surgeon's clinic

Follow up within 48-72 hours

Fracture clinic will contact patient with appointment date and time.