Skip to main content
Hit enter to search or ESC to close
Close Search
Menu
Home
About Dr. Chang
Common Elective Procedures
Total Knee Replacement
Total Hip Replacement
Partial Knee Replacement
Revision Total Knee and Hip Replacement
Knee Arthroscopy and Meniscal Surgery
Anterior Cruciate Ligament (ACL) Reconstruction
Trauma and Fracture Care
Injections
Patient Information
Contact
Wait Times
Wait Times
Home
About Dr. Chang
Common Elective Procedures
Total Knee Replacement
Total Hip Replacement
Partial Knee Replacement
Revision Total Knee and Hip Replacement
Knee Arthroscopy and Meniscal Surgery
Anterior Cruciate Ligament (ACL) Reconstruction
Trauma and Fracture Care
Injections
Patient Information
Contact
General Orthopaedic Patients
Request for Orthopaedic Consultation
Please Fax Referrals To: (416) 291-5554
Download PDF
Step
1
of
2
50%
Referral Date
(Required)
MM slash DD slash YYYY
Referring Physician Information:
Name
(Required)
Specialty
(Required)
Address:
(Required)
Phone
(Required)
Fax
Email Address
(Required)
Billing #
Signature
Family Physician Information (if different):
Name
(Required)
Phone
(Required)
Diagnosis (circle all that apply)
Hip
(Required)
Right
Left
Knee
(Required)
Right
Left
(Required)
Osteoarthritis
Inflammatory arthritis
Fracture/Post-traumatic arthritis
Painful hip or knee replacement
Meniscus Injury or ACL Rupture
Sports Injuries
Patellofemoral Disorders
Past Medical History
(Required)
Patient Information
Name
(Required)
Address
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Health Card #
(Required)
VC
(Required)
Gender
(Required)
Male
Female
Language if unable to speak English
(Required)
Phone (Home)
(Required)
Phone (Work)
(Required)
Phone (Cell)
(Required)
Email
(Required)
Consideration for
Primary Replacement
(Required)
Hip
Knee
Opinion on Prior Replacement
(Required)
Hip
Knee
Arthroscopic Meniscal Surgery
ACL reconstruction
(Required)
Sports Surgery (other)
(Required)
Injections
(Required)
Hip
Knee
Non-Surgical Opinion
(Required)
Hip
Knee
Current Medications
Phone
This field is for validation purposes and should be left unchanged.
Please note
– Wait times for a surgical opinion are between 1-2 months after receiving a consultation from your family doctor or another orthopaedic surgeon.
