Referral Form / Central Intake

Patient Visit

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Patient Visit

Who Should Be Referred?

  • Patients with Low back pain and /or low back-related leg symptoms of at least 6 weeks duration, but no longer than 1 year

  • Patients with unmanageable or recurrent low back pain

  • Patients must be 18 years or older

Who does not qualify?

  • Pain that is a result of an accident (Motor vehicle /workplace covered under WSIB)

  • Conditions that require urgent or emergency care – patients should seek emergency care if required

  • Long-standing low back conditions (greater than 12 months in a row with no relief), as the program is not designed for chronic conditions

  • Patients under the age of 18

  • Pregnant or within 12 months after childbirth (<1 year) 

 What imaging should be completed prior to submitting the referral? 
  • None needed – the goal of the program is to decrease the utilization of imaging

Who will I see?

  • You will be initially assessed by an Advanced Practice Provider (APP), a specially trained physiotherapist or chiropractor, who has undergone additional training with our Spine Surgeons.
  • They have advanced skills and training to provide you with a program that includes a detailed standard assessment and education about your condition.
  • They will work together with both surgeons and your PCP to ensure you get the most appropriate care.
  • The APP will determine the best course of management and if required, recommend diagnostic imaging or consultation with a surgeon.
  • Patients who require a surgical consultation can choose the “first available” surgeon and will experience shorter wait times or can choose a surgeon or hospital of their choice. 
  • If applicable, appointments with the Spines Surgeon will vary based on each surgeon.

What will my appointment with the APP consist of?

  • To optimize your time with the APP, we recommend that you download and complete the patient intake form prior to your first appointment.
  • Review your medical history, surgical history, medication, and functional limitations
  • Comprehensive physical examination
  • Personalized treatment plan
    • **If more investigations are needed, you will be referred to the Practice Lead for surgical triage
  • If required, recommend diagnostic imaging or consultation with a surgeon
  • Potential follow-up visits (from 1-4)

Will the APP provide treatment?

  • The APP for the RAC – LBP does not provide treatment (hands-on therapy).  It is an inter-professional shared care model that provides evidence informed assessment, education and personalized self-management plan.
  • Self-management plans include advice on staying active, as well as instruction on exercises and modified activities as needed.
  • Patients can also be connected to services in their local community if they need more supervised care.

How long will I wait for an assessment? 

  • Ministry of Health has mandated that patients be assessed by an APP within 4 weeks of receiving the referral 

How long is my appointment?

  • Initial appointments are roughly 60 minutes
  • Follow-up appointments are roughly 30 minutes  

What should I bring?

  • Health Card
  • List of medication, including over-the-counter medication , and an allergy list


  • If you are unable to keep your appointment or need to change it for any reason; please notify the clinic within 2 business days of your scheduled appointment.