CPM Centres for Pain Management – Central Intake Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7

P: 905 288-1022 TF: 800 265-3429 Ext 1022 F: 905 858-0111 TFF: 877 883-3301

CPM Patient Referral Checklist

To optimize our central intake and referral process please include ALL required information

outlined in the checklist:

❑ Diagnostic Imaging - MRI and CT Reports of the affected areas no older than 5 years

❑ Medical history and list of medications

❑ Relevant consultation, treatments and surgical notes

❑ MD/Nurse Practitioner demographic and billing number (see note below)

❑ Cumulative Patient Profile (CPP)

IMPORTANT:

Did you know?

CPM has GP Focused Based Practice Physicians available for rostered patients.

Telephone Consultation

A service where the referring physician/nurse practitioner requests the opinion and

expertise of a CPM physician. It allows the PCP/NP the opportunity to ask questions

regarding their patient with chronic pain so they can;

a) Continue providing ongoing treatment and/or;

b) Refer them to a CPM pain clinic

CPM Centres for Pain Management Central Intake Department

Head Office: 9-6400 Millcreek Drive, Mississauga, ON, L5N 3E7 P: 905 288-1022 TF: 800 265-3429 Ext 1022 F: 905 858-0111 TFF: 877 883-3301

Roman D Jovey, MD

Medical Director

Dear Primary Care Practitioner,

Thank you for referring your patient with chronic pain to one of our CPM centres for assessment and/or treatment. I would like to highlight some of the benefits our centres can offer you and your patients.

Timely Assessment of Sub-Acute Pain:

The earlier a patient with pain is treated, the more likely a successful outcome will occur. Painful conditions treated within the first 1-6 months using a multimodal approach have the highest chance of full recovery. Patients with pain for more than 18 months can typically expect some reduction in pain and improvement in the quality of life, but it is unlikely their condition will be resolved. We therefore try to prioritize patients with sub-acute pain.

Timely Access to Multidisciplinary Treatments:

Our goal is to provide comprehensive, caring, chronic pain management whenever possible. Many components of multidisciplinary care are not funded by OHIP. CPM will provide the, 6-week, Chronic Pain Self-Management Program to all CPM patients at no charge. For patients with supplemental health coverage, we can provide other elements of comprehensive care: exercise, massage, cognitive-behavioural therapy, and nutrition counselling etc. For patients without coverage we may refer to community and online resources.

New patient referrals to CPM will be prioritized based on:

a. The need for a one-time consultation vs. a period of active care

b. Duration of the painful condition

c. Extent of 3rd party coverage

Telephone Consultation:

We offer the option of a brief telephone consultation, to better support primary care practitioners (PCPs) or Nurse Practitioners (NPs) whose patients might have to wait to be seen at our centres. This is now a funded service in the OHIP Schedule of Benefits – both for the referring physician/nurse practitioner and the consulting physician. It is suitable for a patient with chronic pain, where there are a small number of specific questions to help the PCP/NP continue ongoing treatment. A specific 1-page referral form can be sent at your request. You can also request telephone consultation patients currently under the care of a CPM physician.

We continually strive to improve our service offerings to referring physicians/nurse practitioners and patients with pain. Please contact our central intake staff if you have any questions or concerns about referring your patients to CPM.

CPM - Centres for Pain Management Referral Form

P: 905.288.1022

TF: 800.265.3429 Ext 1022

F: 905.858.0111

TFF: 877.883.3301

www.cpm-centres.com

Patient email address if available:

Please check applicable practice model:

FHT ☐ FHO ☐ FHG ☐ FHN ☐ FFS ☐ CCM ☐

Please select the preferred clinic location for your patient:

Toronto Mississauga Brampton Scarborough Oakville Oshawa London Ottawa Hamilton

Specific CPM MD:

Is the primary reason for your referral for a specific service/program:

Lidocaine Infusion Y ☐ N ☐ (Available in Oshawa clinic only)

Sub-acute Program Y ☐ N ☐ (Available in Scarborough clinic only)

Primary Pain Diagnosis: _______________________ Secondary Diagnosis: _____________________________

Length of pain complaint: ___________________ Is the patient on blood thinners? Y ☐ N ☐

I acknowledge that I am sending the patient for consultation and possible treatments and I agree

to resume care for this patient after discharge.

Primary Care Practitioner Signature: _________________ Date:

P: 905.288.1022 TF: 800.265.3429 Ext 1022 F: 905.858.0111 TFF: 877.883.3301 www.cpm-centres.com

Last Updated June 2020

Primary Care Practitioner Information: Patient Contact Information:

To expedite the referral please ensure the following is attached:

Copy of your Cumulative Patient Profile (CPP)

Relevant imaging/consultation/operative reports

List of current medications

GP Focused Based Practice Physicians available for rostered patients.

Request for 10 min MD phone conversation? Y N

CPM - Centres for Pain Management

Brampton CPM Oshawa CPM 312 Queen Street East Brampton, ON L6V 1C2 T: 905 458-7377 F: 905 458-7477

500 King Street West, Unit #2 Oshawa, ON L1J 2K9 T: 905 576-3444 F: 905 576-7980

Mississauga CPM Oakville CPM 6400 Millcreek Drive, Unit #9 Mississauga, ON L5N 3E7 T: 905 288-1045 F: 905 858-2144

2125 Wyecroft Road, Unit #6 Oakville, ON L6L 5L7 T: 905 842-7051 F: 905 842-8216

Scarborough CPM London CPM 1200 Markham Road, Suite #425 Scarborough, ON M1H 3C3 T: 416 438-7080 F: 416 438-7072

215 Fanshawe Park Road West, Suite #203 London, ON N6G 5A9 T: 519 434-4727 F: 519 434-4700

Toronto CPM Ottawa CPM 123 Edward Street, Suite #1118 Toronto, ON M5G 1E2 T: 416 593-7700 F: 416 593-7702

1770 Woodward Dr, Unit 100 Ottawa, ON K2C 3J2 T: 613 755-2095 F: 613 731-6201

Hamilton CPM 1605 Main Street West Hamilton, ON L8S 1E6 T: 905 574-4911 F: 905 574-8290