Metal-on-metal hip replacements referral form

You will need to forward all relevant images via IEP/CD.

To refer a patient to the painful metal bearing hip replacement advisory service, please complete the online referral form.

After the referral has been submitted, an automated email reply will confirm the referral has been received (please check your spam folder).

A report of the recommendations of the MDT team will be forwarded to the referrer following the team meeting.

If you would like to discuss anything further, before submitting the form, please contact the MDT coordinator on 020 8909 5279.

Please note, we are happy to provide advice on patients with adverse reactions to metal debris in the absence of a non-metal bearing hip replacement.

These forms are only for tertiary referrals from other hospitals. We will not accept referrals from GPs using the online referral form below.

If you are a GP referring to the RNOH please use the NHS e-referral system, e-RS.

Referring consultant’s details:

Confirmation will be sent to this email.

Patient details:

GP details:

Before we discuss your patient’s case, we require the following information:

Surgery details

Please give details of:

What type of implant does the patient have?
(0 – 48)
Please enter the patient’s oxford hip score
Blood cobalt
Blood chromium
ESR
mm/hr
CRP
mg/L
Painful hip arthroplasty/metal - previous blood test
Blood cobalt
Blood chromium
ESR
mm/hr
CRP
mg/L

If you have any enquiries about this service or wish to provide outstanding test results, please contact the MDT coordinator on 020 8909 5279 or fax 020 8909 5277.

Declaration for MDT reports

  1. Our clinical advisory service is based upon the information presented to us by the referring doctor.
  2. We understand that it is our duty to help on the matters within our expertise and we will comply with that duty.
  3. We will do our best in preparing this report, to ensure that it is accurate and complete. We will mention all matters, which we regard as relevant to the opinions we express. All of the matters on which we express an opinion lie within our field of expertise.
  4. We will draw attention to all matters, of which we are aware, which might adversely effect our opinion.
  5. Wherever we have no personal knowledge, we will indicate the source of factual information.
  6. We will not include anything in this report, which has been suggested to us by anyone, without forming our own independent view of the matter.
  7. Where, in our view, there is a range of reasonable opinion, we will attempt to indicate the extent of that range in the report.
  8. At the time of sending the report, we will consider it to be complete and accurate. We will notify the referrer if, for any reason, we subsequently consider that the report requires any correction or qualification.
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Painful metal-on-metal hip replacements