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Regional Hip and Knee Replacement Program
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Regional Information Sheet

Consultation Instructions

Referral Form

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Consultation Instruction Sheet

The Champlain LHIN has had a central intake process for referrals for primary hip and knee replacement surgery, since January 4, 2010.

Rather than sending a referral directly to an orthopaedic surgeon’s office, the “Request for Primary Hip and Knee Replacement Consultation” referral form should be completed. This referral is a standardized form and should be faxed to the Regional Hip and Knee Replacement Program Central Intake Centre at 613-721-7889.

Referrals not received on this form will be sent back to the referring physician to complete - resulting in delays for your patients. Please review the following instructions to familiarize yourself with the process and new referral form.


Referring Physician’s Office:

  1. Complete the “Request for Primary Hip and Knee Replacement Consultation”. We strongly encourage you to complete all fields on the form and provide additional information where appropriate.

  2. Fax the “Request for Primary Hip and Knee Replacement Consultation” form to the Central Intake Centre at 613-721-7889.

  3. If any of the required information is missing, the “Request for Primary Hip and Knee Replacement Consultation” will be faxed back to your office to be completed.

  4. If the patient is deemed not appropriate for assessment ie. patient referred for shoulder, feet, back assessment, your office will receive a notification stating the reason for the decision.

  5. Patients will be contacted directly by the assessment centre closest to their home: Cornwall Community Hospital, Hôpital Montfort, or Queensway Carleton Hospital and scheduled for an appointment.

  6. If the patient is a surgical candidate, they will be provided with wait list information and may choose a hospital, a surgeon or the first available surgeon to consult at any of the participating hospitals: Cornwall Community Hospital, Hôpital Montfort, The Ottawa Hospital or The Queensway Carleton Hospital.
If you have any questions about this form or about the process, please call the Regional Hip and Knee Replacement Program Central Intake Centre at 613-721-7890.