"Referral for Orthopaedic surgery at Osborne Park Hospital"
Referral for Orthopaedic surgery at Osborne Park Hospital Osborne Park Hospital Referral for GP details/stamp: Type of surgery & reason: Patient details: Name: DOB: Address: Telephone: Home: Work: Mobile: UMRN: Medicare no: Relevant PMH: Medication History: Allergies/ drug reactions: This patient does NOT have any of the following exclusion criteria: Severe obesity Weight > 120 kg or BMI >40 Severe or unstable cardiovascular Marked limitation of activity, poorly controlled hypertension or disease ischaemic heart disease, uninvestigated murmurs (if murmur requires an echocardiogram pre-op) Unstable respiratory disease On >10 mg prednisolone, severely compromised lung function (PEFR < 50% of expected) or obstructive sleep apnoea on CPAP Poorly controlled diabetes HbA1C >8, on >30 U insulin/day Liver failure ie. bilirubin raised. Minor rise in GGT okay Renal failure creatinine > 150 History of significant anaesthetic eg. malignant hyperthermia problems Severe rheumatoid systemic disease eg. unstable cervical spine, lumbar spinal deformation, severe with unstable symptoms and/or systemic joint deformation/contractures advanced joint decay Complex metabolic/endocrine conditions stable single systems, eg. treated hypothyroidism okay Unstable neurological disorders eg. advanced Parkinson’s disease Complex psychiatric and chronic pain conditions Revision surgery Date: Thank you. Please fax to Osborne Park Hospital on 9346 8215. Enquiries 9346 8010. Please ensure the patient has recent plain X-rays (within 6 months of referral). Osborne Place, Stirling, Western Australia 6021 Telephone (08) 9346 8000 Facsimile (08) 9346 8008 Website: http://www.oph.health.gov.au ABN: 13 993 250 709