Health

DSRTF - Out of Province Patient Enquiry

Javascript must be enabled to complete this form. Please see https://www.enablejavascript.io for more information.

Diagnostic and Surgical Recovery Task Force - Out of Province Patient Enquiry

Foot, Ankle and Shoulder Surgeries

Patients to self-verify if they meet the criteria for out of province foot, ankle or shoulder surgery.

Fit for travel as determined by Surgeon
BMI < 45 – weight within a normal range
Full COVID-19 vaccination (two doses) – the purpose of this requirement is to reduce the chance of contracting COVID-19 and its subsequent potential impact on recovery
On a waitlist for other orthopedic surgeries i.e.: Shoulder, Foot, Ankle or Arthroscopy
Stable heart condition or no heart problems
Stable asthmatic or chronic lung conditions
Not on home oxygen
Kidney function – no dialysis patients
Well controlled diabetes
No recent history of stroke or mini stroke within the past year
No known aneurism or blood vessel condition
No liver conditions
No immunosuppression
No low iron in blood that needs further follow up or investigation
Not on chemotherapy or awaiting cancer surgery
No muscle conditions such as Muscular Dystrophy
No self-reported cognitive impairment that would prevent travelling out of province with a support person for surgery
Ambulatory patients

Full name

Telephone number (home)

Referring surgeon

Type of surgery patient is waiting for

Acknowledgement

I give my consent to the disclosure of my personal information that I have provided, for the purpose of determining eligibility for out-of-province surgery. I acknowledge that patient information will be treated as confidential, in compliance with The Freedom of Information and the Protection of Privacy Act (FIPPA) and The Personal Health Information Act (PHIA). It will only be utilized or revealed for the purpose of determining edibility and referral to an out-of-province provider unless authorized or mandated by FIPPA, PHIA or another Manitoba or Canadian legislation.

I give my consent for the Diagnostic and Surgical recovery Task Force (DSRTF) team to contact me via email or telephone in response to my out of province submission. Note, you will only be contacted if you are on a waitlist for foot, ankle, or shoulder surgery.

By checking this box, I declare that I have read, understand and consent to the above statements.

DSRTF - Out of Province Patient Enquiry

Diagnostic and Surgical Recovery Task Force - Out of Province Patient Enquiry Foot, Ankle and Shoulder Surgeries

Acknowledgement

Diagnostic and Surgical Recovery Task Force - Out of Province Patient Enquiry

Foot, Ankle and Shoulder Surgeries