Ortho Connect Client Request For Services
Register with the Ortho Connect Peer Support Program

Please take a moment to fill in the following information. We will use the information you provide to select the best volunteer match for you. We will be in touch with you in the next day or so. It is our goal to have you matched within 48 hours.

Full Name: Gender:
Mailing Address:
City: Province:
Postal Code:
Home Phone: Work Phone: Cell Phone:
Date of Birth: (dd/mm/yyyy) - age is one of the criteria we use to make client matches
E-mail Address:
Occupation:
Are you an Orthopaedic Patient?:
If no, indicate relationship to patient::
Type of Orthopaedic Surgery:
Surgeon:
Hospital:
Has a date been set for your surgery? If yes, date for surgery (dd/mm/yyyy):
What questions would you like to ask your Ortho Connect Volunteer?

What concerns do you have regarding your upcoming surgery?

What topics would you like to discuss with your volunteer:
Other:

When is the best time for your volunteer to call?
Please check your preference:
Please indicate your availability:
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.
To be matched with someone who speaks a language other than English:
Other:
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.