PMO RAPID ORTHOPEDIC C PACIFIC ORTHOPEDICS AND SPORTS MEDICINEpacificortho.ca/files/POSM ROCC...
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SAMLER (Shoulder, Elbow, Knee) Spine: please refer to Neurosurgery Hand: please refer to Plastic Surgery (Subspecialty Interests) R APID O RTHOPEDIC C ONSULTATION C LINIC (ROCC) Body Part Foot / Ankle Shoulder / Arm Diagnosis Arthritis Fracture Soft Tissue Injury Other Orthopedic Surgeon BAGGOO (Knee, Foot, Ankle) JANDO (Hip, Knee) SIDKY (Hip, Knee) ZARKADAS (Shoulder, Elbow, Knee) X-Ray Requirement Please attach the requested X-ray reports. Hand & Wrist (AP and Lateral) Imaging Location Lions Gate Hospital North Shore Medical Imaging Squamish General Hospital Other Other Medical Imaging MRI Ultrasound 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, First Last, 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. P M S O Tel: 604-980-0504 • Fax: 604-980-0531 Name Hip / Pelvis Knee / Leg Wrist Elbow / 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) CT Nuclear Medicine Whistler Health Care Centre Sechelt Hospital P ACIFIC O RTHOPEDICS AND S PORTS M EDICINE For urgent assessments, please contact the surgeon on-call directly or via the LGH switchboard at 604-988-3131. North Shore
Transcript of PMO RAPID ORTHOPEDIC C PACIFIC ORTHOPEDICS AND SPORTS MEDICINEpacificortho.ca/files/POSM ROCC...
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
