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ucihealth.org UCI Health Department of Orthopaedic Surgery UC Irvine Medical Center Pavilion 3 101 The City Dr. South Orange, CA 92868 UCI Health Orthopaedic & Sports Medicine Center Pacific Medical Plaza 1640 Newport Blvd., Suite 230 Costa Mesa, CA 92627 714-456-7012 (phone) 714-509-2168 (fax) New Patient Orthopaedic and Spinal Surgery Date: Patient Information Preferred Physician: (if any; please see reverse for a full physician roster) Reason for Referral (Check all that apply) Referring Physician: Patient Name Date of Birth Home Phone Cell Phone Physician Name/Group Telephone Office Address Fax City State Zip Email Preferred Method of Communication q Phone q Email q Fax q Letter Our team works with referring physicians to coordinate care and ensure timely communication regarding the status of your patient. Physician communication by mobile phone is available. It is our goal to return patients to your care as quickly as possible. Please fax completed form to 714-509-2168 with a copy of the patient’s insurance card (front and back) and clinical records. SPINE q Cervical q Thoracic q Lumbar Diagnosis __________________________ UPPER EXTREMITY/HAND q Shoulder q Elbow q Hand and wrist Diagnosis __________________________ FRACTURE CARE q Acute fracture (if urgent, please call 714-456-7012) q Malunion q Non-union Diagnosis __________________________ JOINT REPLACEMENT q Hip q Knee q Shoulder q Elbow q Ankle Diagnosis __________________________ COMPREHENSIVE HIP CARE q Labral tear q Arthritis q Avascular necrosis q Dysplasia/Peri-acetabular osteotomy evaluation SPORTS MEDICINE q Shoulder q Knee q Hip Diagnosis __________________________ FOOT AND ANKLE Diagnosis __________________________ ONCOLOGY q Bone tumor/mass q Soft tissue tumor/mass q Metastatic bone disease Diagnosis __________________________

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Page 1: New Patient UCI Health 101 The City Dr. South Orthopaedic ...orthopaedicsurgery.uci.edu/pdf/OrthopaedicSpinalSurgery-Referral.pdfFracture care and hip preservation Yu-Po Lee, MD Complex

ucihealth.org

UCI HealthDepartment of Orthopaedic Surgery

UC Irvine Medical Center Pavilion 3 101 The City Dr. South

Orange, CA 92868

UCI Health Orthopaedic & Sports Medicine Center

Pacific Medical Plaza 1640 Newport Blvd., Suite 230

Costa Mesa, CA 92627

714-456-7012 (phone)714-509-2168 (fax)

New PatientOrthopaedic and Spinal Surgery

Date:

Patient Information

Preferred Physician: (if any; please see reverse for a full physician roster)

Reason for Referral (Check all that apply)

Referring Physician:

Patient Name Date of Birth

Home Phone Cell Phone

Physician Name/Group Telephone

Office Address Fax

City State Zip

Email Preferred Method of Communicationq Phone q Email q Fax q Letter

Our team works with referring physicians to coordinate care and ensure timely communication regarding the status of your patient. Physician communication by mobile phone is available. It is our goal to return patients to your care as quickly as possible.

Please fax completed form to 714-509-2168 with a copy of the patient’s insurance card (front and back) and clinical records.

SPINEq Cervical

q Thoracic

q Lumbar

Diagnosis __________________________

UPPER EXTREMITY/HANDq Shoulder

q Elbow

q Hand and wrist

Diagnosis __________________________

FRACTURE CAREq Acute fracture (if urgent, please call 714-456-7012)

q Malunion

q Non-union

Diagnosis __________________________

JOINT REPLACEMENTq Hip

q Knee

q Shoulder

q Elbow

q Ankle

Diagnosis __________________________

COMPREHENSIVE HIP CAREq Labral tear

q Arthritis

q Avascular necrosis

q Dysplasia/Peri-acetabular osteotomy evaluation

SPORTS MEDICINEq Shoulder

q Knee

q Hip

Diagnosis __________________________

FOOT AND ANKLEDiagnosis __________________________

ONCOLOGYq Bone tumor/massq Soft tissue tumor/massq Metastatic bone disease

Diagnosis __________________________

Page 2: New Patient UCI Health 101 The City Dr. South Orthopaedic ...orthopaedicsurgery.uci.edu/pdf/OrthopaedicSpinalSurgery-Referral.pdfFracture care and hip preservation Yu-Po Lee, MD Complex

Our team

Nitin N. Bhatia, MDComplex spine surgery

Ranjan Gupta, MDShoulder, elbow and hand surgery

Andrew R. Hsu, MDFoot and ankle surgery

Neil F. Jones, MDHand surgery and reconstructive microsurgery

P. Douglas Kiester, MDComplex spine surgery

James R. Learned, MDFracture care and hip preservation

Yu-Po Lee, MDComplex spine surgery

William C. McMaster, MDHip and knee arthroplasty

Contact UsFor more information or to make an appointment, call 714-456-7012.

Locations

UC Irvine Medical Center 101 The City Dr. South Pavilion 3 Orange, CA 92868 Phone: 714-456-7012 Fax: 714-456-8711

UCI Health Orthopaedic & Sports Medicine Center Pacific Medical Plaza 1640 Newport Blvd., Suite 230 Costa Mesa, CA 92627 Phone: 714-456-7012 Fax: 949-631-3860

ucihealth.org/ortho

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John A. Scolaro, MDTrauma and fracture care

David H. So, MDHip and knee replacement

Russell Stitzlein, MDOncology, sarcomas, tumors

Martin C. Tynan, MDTrauma

Dean Wang, MDSports medicine