Request for Services

An “Ortho Connect” Client is an orthopaedic patient, family member, friend or caregiver who would like to connect with someone who has already experienced orthopaedic surgery.

Your Name*:

Gender:

Mailing Address*:

City*:

Province*:

Postal Code*:

Home Phone:

Cell Phone:

Work Phone:

Patient's Date of Birth*:
age is one of the criteria we use to make client matches

Email Address*:

In order to facilitate contact, we will be providing your home number, cell phone number and email address to our volunteer.

 

Patient's Occupation*:

Are you an orthopaedic patient?*:

If no, indicate relationship to patient:

Type of Orthopaedic Surgery*:

Surgeon*:

Hospital*:

If a date has been set for the surgery, please enter it here:

What questions would you like to ask the Ortho Connect Volunteer?

What concerns do you have regarding the upcoming surgery?

What topics would you like to discuss with the volunteer:

Other:

When is the Best Time for the Volunteer to Call?

Matching Information
The following information will assist us to match you with a Volunteer. Please indicate your preferences:

To be matched with someone of the same gender.

If you would like to be matched with someone who speaks a language other than English, please enter the language:

How did you hear about the Ortho Connect peer support program?

Other:

I certify that the information provided is accurate. I understand that my participation in the program depends on the availability of a suitable Volunteer and my compliance with the policies and procedures of the Ortho Connect program. I also give the Canadian Orthopaedic Foundation permission to contact me.

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