KINGSTON ORTHOPAEDIC PAIN INSTITUTE
Referrals
Welcome to KOPI's Referral Page. Please click on the name of the form to fill or download.
Submit via fax 613-344-1203 or email intakeforms@kopi.ca.
01
KOPI accepts referrals from Physicians and Nure Practitioners for chronic pain management. Please download the form using the link above.
02
KOPI accepts referrals from both physicians and allied health professionals for our Sports Medicine Clinic. Please include a detailed referral along with the following:
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Reason for the Referral
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Date of injury
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Recent imaging
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Patient’s previous treatments
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Please click the link above to complete our referral form for the Sports Medicine Clinic.
03
KOPI will only accept physician referrals for our Orthopaedic Clinic. Please include a detailed referral along with the following:
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For Dr Jeff Yach and Dr Faizal Kassam please include an updated MRI (within the past year).
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Please send referrals for Dr Davide Bardana to fax # 613 548 1336, attention Melissa, along with x-rays dated within the past 6 months.
Please click the link above to complete our referral form for the Orthopaedic Clinic.
04
KOPI will accept both physician and allied healthcare professional referrals for our Concussion clinic. Please include a detailed referral along with the following: Date and details of injury.
Please click the link above to complete a referral for the Concussion Clinic.
05
The referral can be filled out and sent to our clinic via fax by all health clinicians.
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*THIS FORM IS NOT FOR PATIENTS USE*
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Please attach relevant imaging including notes and history.
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PATIENTS interested in this treatment can self-refer to our regenerative medicine clinic by calling 613-985-7836 or emailing regen@kopi.ca.
06
KOPI's Ketamine Clinic requires a referral to be filled out by a primary care physician or psychiatrist.
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*THIS FORM IS NOT FOR PATIENTS USE*
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Referrals that are accepted to our program will be contacted to fill out our intake questionnaires.
Once it is completed patients will complete a full medication review and consultation with either a pain specialist or our psychiatrist Dr. J. Pikard.
07
To refer a patient for Botox services, please complete the referral form linked above.
We look forward to collaborating with you to enhance the well-being of your patients.
Please fax the document to (613) 344-1203, or email the completed referral form to intakeforms@kopi.ca.
