Refer Your Patients to Dr. Wood

• Patient First Name (required)
• Patient Last Name (required)

• Patient Date of Birth

  • Month
    Month January February March April May June July August September October November December
  • Date
    Date 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
  • Year
    Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
• Ministry of Health Number
• Patient Email
• Patient Phone 1
• Patient Phone 2
• Patient Street Address
• Patient Address Line 2
• Patient City
• Patient Province
  Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland/Labrador Nova Scotia Northwest Territories Nunavut Prince Edward Island Quebec Saskatchewan Yukon
• Patient Postal Code

End Section 1 of 3 (Patient Info)

• Physician First Name (required)
• Physician Last Name (required)
• Physician Email (required)
• Physician Phone (required)
• Physician Phone 2
• Physician Fax
• Physician Street Address (required)
• Physician Address Line 2
• Physician City (required)
• Physician Province (required)
  Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland/Labrador Nova Scotia Northwest Territories Nunavut Prince Edward Island Quebec Saskatchewan Yukon
• Physician Postal Code (required)
• OHIP Billing Number (required)
• Why Referring (required)

End Section 2 of 3 (Physician Info)

• Previously seen patient?

  Yes No Unknown

• Joint Affected:

  Hip Knee Other
• Syptoms and Duration of Symptoms
• Restricted Activities of Daily Living
• Other Activities Affected
• Treatments to Date (e.g physio, injections)

• Does Patient Use Any Transportation Aids? (e.g. cane, walker, wheelchair)

  Yes No Unknown

• Is Patient Using Pain Medication?

  Yes
  No Unknown
• Patient Medical History

• Investigations/Examinations Completed

  X-Ray MRI CT Scan Other

• Patient Exam Reports will Accompany Referral Fax

  Yes No

• Have you asked the patient if condition warrants surgery?

  Yes No

• Would the patient have surgery?

  Yes No

• Family Physician's & Patient's Primary Objective

  Consultation to look at alternatives to surgery
  Second opinion
  Joint injection
  Discuss future of patient's condition
  Discuss surgical options
  Unsure of diagnosis and seeking explanation for complaint
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End Section 3 of 3 (Additional Info)