403-233 Nelson's Crescent
New Westminster, BC CAN V3L 0E4
View Map
Contact Us
Home Physician Referral Form

Physician Referral Form

    PATIENT INFORMATION: (affix label or complete)

    YesNo  

    REFRRRING PHYSICIAN: (affix label or complete)

    (Cell phone and email's are mandatory, as the patient will be sent a patient questionnaire to be filled out prior to their appointment)

    REASON FOR VISIT:

    HipKneeFoot/AnkleShoulder/Elbow/WristHand/Fingers

    ACUTE INJURY REFERRALS:

    Patients that require assessments urgently (e.g. fracture or infection) are considered URGENT REFERRALS and should be faxed to our Fraser Orthopaedic Treatment Clinic at 1.866.2756106

    DIAGNOSIS AND TREATMENT TO DATE:

    CURRENT MEDICATIONS:

    ALLERGIES::

    ALL PATIENT'S REQUIRES MEDICAL IMAGING FOR TRIAGE

    Have x-rays of the affected area been obtained? Yes, reports attachedNo

    ELECTIVE MUSCULOSKELETAL REFRRAL & WORKSAFEBC SPORTS MEDICINE ASSESSMENT

    Dr. Deneen Baron (Shoulder & Knee, WorkSafeBC Assessment)Dr. Stephanie Anderson (Foot/Ankle)Dr. Sara ForsythFirst Available Physician

    Fax referrals to 1-866-275-6106 Phone: 604-549-4102 ext.# 1

    ORTHOPAEDIC SURGEON

    Dr. Kelly Apostle (Foot & Ankle) / Fax referral to 778-312-0134Dr. Dory Boyer (Lower Extremity Sports Injuries) / Fax referral to 1-877-679-1960Dr. Farhad Moola (Shoulder, Elbow, Wrist and Hand) / Fax referral to 1-866-883-1615Dr. Bertrand Perey (Elbow, Wrist and Hand) / Fax referral to 604-525-2628Dr. Trevor Stone (Pelvis, Hip and Knee) / Fax referral to 778-312-0118Dr. Darius Viskontas (Pelvis, Hip and Knee) / Fax referral to 604-777-5644

    Upon review, receipt of referral will be confirmed via fax to referring physician’s office. Our MSK office or surgeon’s office will contact patients or referring physician’s office by either phone or fax once a scheduled appointment date has been made. Please refrain your patients from calling the offices inquiring about their referrals and wait times.