All referral forms on this website are also available as eForms for OSCAR, Avaros, Indivicare, and ACCURO EMRs. You can download some of the premade forms here from WorldEMR or fill the contact form below for any other eForms that are not listed for your EMR.
For the SouthWest Musculoskeletal Rapid Access Clinic (orthopedic consult) see MSK section
Table of Contents
Clinics
| Clinics | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| SWLHIN Rapid Access Clinic for Low Back Pain | 1. Low Back Pain | SWLHIN Low Back Pain Rapid Access Clinic Referral | Fax: 1-855-470-6584 | Fax Referral PCPs must registered to be able to refer Register Here | |
| SWLHIN Rapid Access Clinic for Knee & Hip Arthritis | 1. Hip Arthritis 2. Knee Arthritis | LHSC – University Hospital St. Thomas Elgin General Hospital Strathroy Middlesex General Hospital Stratford General Hospital Woodstock Hospital Grey Bruce Regional Health Service | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Fax: 1-855-526-5322 | Fax Referral Must x-ray affected joint |
| Spine Centre Dr. Bailey, Chris Dr. Gurr, Kevin Dr. Rasoulinejad, Parham Dr.Siddiqi, Fawaz (Neuro Surg) | 1. Spine Surgery | LHSC – Victoria Hospital | Spine Centre Referral Form | Phone: 519-685-8055 Fax: 519-685-8059 | Fax Referral |
| Hand and Upper Limb Clinic | 1. Medical and Surgical Care for hands and upper limbs | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form HULC ER Urgent Referral Form | Phone: 519-646-6000 ext 64944 Fax: 519-646-6049 | Fax Referral Website |
| LHSC ER Ortho Clinic Referral (VH Only) | 1. Orthopedic Surgery | LHSC – Victoria Hospital | VH Outpatient Referral | Phone: 519-685-8500 x 56350 Fax: 519-685-8447 | Fax consult Office to call patient |
London
| London | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Athwal, George | 1. Orthopedic Surgeon 2. Shoulder 3. Elbow | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6081 Fax: 519-646-6049 | Fax Referral Website |
| Dr. Drosdowech, Darren | 1. Orthopedic Surgeon 2. Shoulder | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6047 Fax: 519-646-6049 | Fax Referral Website |
| Dr. Faber, Kenneth | 1. Orthopedic Surgeon 2. Shoulder 3. Elbow 4. Wrist | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6312 Fax: 519-646-6049 | Fax Referral Website |
| Dr. Grewal, Ruby | 1. Orthopedic Surgeon 2. Hand 3. Wrist | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6011 Fax: 519-646-6049 | Fax Referral Website |
| Dr. King, Graham | 1. Orthopedic Surgeon 2. Elbow 3. Wrist | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6011 Fax: 519-646-6049 | Fax Referral Website |
| Dr. LeBel, Marie-Eve | 1. Orthopedic Surgeon 2. Shoulder | St. Joseph’s Hospital Room D0-101 268 Grosvenor Street London, Ontario N6A 4V2 | HULC Referral Form | Phone: 519-646-6153 Fax: 519-646-6049 | Fax Referral Website Speaks French |
| Dr. Lawendy, Abdel-Rahman | 1. Orthopedic Surgery 2. Trauma 3. Foot & Ankle | LHSC – Victoria Hospital | Generic Form | Phone: 519-685-8500 ext 58218 Fax: 519-685-8059 | Fax consult Speaks Arabic |
| Dr. MacLeod, Mark | 1. Foot and Ankle Surgery 2. Post Trauma reconstruction | LHSC – Victoria Hospital | Generic Form | Phone: 519-685-8500 ext 53059 Fax: 519-685-8059 | Fax consult |
| Dr. Sanders, David | 1. Orthopedic Surgery 2. Foot & Ankle 3. Post Trauma Reconstruction | LHSC – Victoria Hospital | Generic Form | Phone: 519-685-8086 Fax: 519-685-8016 | Fax consult |
| Dr. Howard, James | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3551 Fax: 519-663-3775 | Fax consult |
| Dr. Lanting, Brent | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-685-8500 ext 33335 Fax: 519-663-3838 | Fax consult |
| Dr. MacDonald, Steven | 1. Knee & Hip Replacements & Revisions Only | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3689 Fax: 519-663-3096 | Fax consult |
| Dr. McCalden, Richard | 1. Knee & Hip Replacements & Revisions Only | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3049 Fax: 519-663-3208 | Fax consult |
| Dr. Naudie, Douglas | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3407 Fax: 519-663-3420 | Fax consult |
| Dr. Schemitsch, Emil | 1. Orthopedic Surgery 2. Knee & Hip Arthroplasty | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3307 Fax: 519-663-3043 | Fax consult |
| Dr. Vasarhelyi, Edward | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | LHSC – University Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral | Phone: 519-663-3413 Fax: 519-663-3417 | Fax consult |
| Dr. Heaven, Sebastian | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction 3. Spine Referrals (Triage) | Medpoint – Citi Plaza | Generic Form | Phone: 51-432-1919 ext. 264 Fax: 519-432-9529 | Fax consult |
| Dr. Degen, Ryan | 1. Orthopedic Surgery 2. Sports Medicine (Shoulder, Hip, Knee) | Western University – 3M Centre – Fowler Kennedy Sport Medicine Clinic | FK – Ortho Referral Form | Phone: 519-661-2171 Fax: 519-661-4237 | Fax consult |
| Dr. Getgood, Alan | 1. Orthopedic Surgery 2. Sports Medicine (Knee) | Western University – 3M Centre – Fowler Kennedy Sport Medicine Clinic | FK – Ortho Referral Form | Phone: 519-661-4003 Fax: 519-850-2991 | Fax consult |
| Dr. Giffin, Robert | 1. Orthopedic Surgery 2. Sports Medicine (Knee) | Western University – 3M Centre – Fowler Kennedy Sport Medicine Clinic | FK – Ortho Referral Form | Phone: 519-661-3454 Fax: 519-850-2496 | Fax consult |
| Dr. Litchfield, Robert | 1. Orthopedic Surgery 2. Sports Medicine (Shoulder, Knee) | Western University – 3M Centre – Fowler Kennedy Sport Medicine Clinic | FK – Ortho Referral Form | Phone: 519-661-4156 Fax: 519-850-2497 | Fax consult |
| Dr. Willits, Kevin | 1. Orthopedic Surgery 2. Sports Medicine (Shoulder, Hip, Knee, Ankle) | Western University – 3M Centre – Fowler Kennedy Sport Medicine Clinic | FK – Ortho Referral Form | Phone: 519-661-4121 Fax: 519-850-2484 | Fax consult |
| Dr. Okusanya, Olanrewaju | 1. Orthopedic Surgery | Sheer Health Medical Clinic 1476 Aldersbrook Rd London, ON N6G 0P5 | Generic Form | Phone: 519-474-7300 Fax: 519-474-7309 | Fax consult Website |
Strathroy
| Strathroy | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Chant, Chris | 1. Orthopedic Surgery 2. Sports Medicine | Strathroy Middlesex General Hospital | Generic Form | Phone: 519-246-9797 ext 5252 Fax: 519-246-9796 | Fax consult |
| Dr. Rajgopal, Raghav | 1. Orthopedic Surgery 2. Foot & Ankle 3. Lower Limb Reconstruction 4. Trauma | Strathroy Middlesex General Hospital | Generic Form | Phone: 519-245-5775 Fax: 519-245-7806 | Fax consult |
| Dr. Rajgopal, Vaishnav | 1. Orthopedic Surgery | Strathroy Middlesex General Hospital | Generic Form | Phone: 519-245-5775 Fax: 519-245-7806 | Fax consult |
Stratford
| Stratford | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Guy, James | 1. Orthopedic Surgery | 386 Cambria St, Unit 104 Stratford, ON N5A 1J4 | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral Generic Form | Phone: 519-272-1811 Fax: 519-272-1822 | Fax consult Speaks French |
| Dr. Pototschnik, Ralph | 1. Orthopedic Surgery | 342 Erie Street Unit 115 Stratford ON N5A 2N4 | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral Generic Form | Phone: 519-272-2727 Fax: 519-272-2729 | Fax consult |
St. Thomas
| St. Thomas | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Sellan, Michael | 1. Orthopedic Surgery | St Thomas Elgin General Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral Elgin Ortho ER Referral | Phone: 519-637-8308 Fax: 519-207-8308 | Fax consult |
| Dr. Van Houwelingen, Andrew | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | St Thomas Elgin General Hospital | SWLHIN Hip & Knee Arthritis Rapid Access Clinic Referral Elgin Ortho ER Referral | Phone: 519-637-8308 Fax: 519-207-8308 | Fax consult |
Woodstock
| Woodstock | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Petis, Stephen | 1. Orthopedic Surgery | 333 Athlone Ave, Suite 104 Woodstock, ON N4V 0B8 | Generic Form | Phone: 519-533-6970 Fax: 519-533-6971 | Fax consult |
| Dr. Bigham, Aaron | 1. Orthopedic Surgery | 333 Athlone Ave, Suite 104 Woodstock, ON N4V 0B8 | Generic Form | Phone: 519-290-9001 Fax: 519-290-9002 | Fax consult |
| Dr. Tran, Michael | 1. Orthopedic Surgery | 333 Athlone Ave, Suite 104 Woodstock, ON N4V 0B8 | Generic Form | Phone: 519-533-6968 Fax: 519-533-6969 | Fax consult |
| Dr. Xenoyannis, George | 1. Orthopedic Surgery 2. Knee & Hip Reconstruction | 333 Athlone Ave, Suite 104 Woodstock, ON N4V 0B8 | Generic Form | Phone: 519-290-2461 Fax: 519-286-0472 | Fax consult |
Tillsonburg
| Tillsonburg | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Inculet, Clayton | 1. Orthopedic Surgery 2. Foot & Ankle | 167 Rolph Street Tillsonburg, ON N4G 3Y9 | Generic Form | Phone: 519-688-5625 Fax: 519-688-5605 | Fax consult |
Pediatric Physicians
| Pediatric Physicians | Subspecialty / Interest | Location | Form | Contact | Information |
|---|---|---|---|---|---|
| Dr. Bartley, Debra | 1. Pediatric Orthopedic Surgery 2. Sports Medicine | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-685-8021 Fax: 519-685-8038 | Fax consult |
| Dr. Carey, Timothy | 1. Pediatric Orthopedic Surgery 2. Scoliosis | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-685-8021 Fax: 519-685-8038 | Fax consult |
| Dr. Cashin, Megan | 1. Pediatric Orthopedic Surgery | Children’s Hospital London Health Sciences Centre | Generic Form | Phone: 519-685-8021 Fax: 519-685-8038 | Fax consult |
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