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Admission, Referral and Other Hartford Hospital Forms

The following forms* may be used when admitting a patient to Hartford Hospital.
 
Admission Forms:
Form Name HH DPC # Rev. Posted
Ambulatory Record 571099 11/06 01/17/08
Authorization for Transfusion Blood/Blood Products (English) 577090 02/09 03/17/09
Authorization for Transfusion Blood/Blood Products (Spanish) 577092 03/09 03/17/09
Cardiology PC - Consultation/Admission Report 571845 05/08 09/23/08
Elective Admission/Surgery H&P Form 571048(edds) 11/06 12/11/06
Informed Consent (English) 571084 02/08 03/13/08
Informed Consent (Spanish) 571127 07/07 01/17/08
Open Heart Surgery Consent (English) 577070 02/08 02/28/08
Open Heart Surgery Consent (Spanish) 577071 02/08 02/28/08
Patient Pre-Admission Questionnaire 571094 11/06 12/21/06
 
Physician's Order Forms:
Form Name HH DPC # Rev. Posted
C8 Admission Orders 549429-HH9427 03/06 12/01/06
Pre-Op Ambulatory Surgery 549438-HH9438 03/06 12/01/06
Pre-Op Laproscopic Cholecystectomy 549328C 01/09 02/04/09
Pre-Op Bowel 549328A 01/09 02/04/09
Pre-Op Lumbar Fusion 549316 01/09 02/04/09
Pre-Op Total Joint 546808D 01/09 02/11/09
Pre-Op Open Heart 549460 06/07 08/13/07
Pre-Op Lapropscopic Nissen Fundoplication/Heller Myotomy 549437 01/09 02/04/09
 
Referral/Requisition Forms:
Form Name HH DPC # Rev. Posted
Cardiac Rehabilitation Referral 571979 12/08 02/11/09
Imaging Center Requisition 546231-HH6231 09/08 02/04/09
Sleep Disorder Center Referral Form 571922 06/09 06/10/09
 
Miscellaneous Forms:
Form Name HH DPC # Rev. Posted
Sleep Disorder Center Epworth Sleepiness Scale (English & Spanish) 571629 10/08 02/04/09
Sleep Disorder Center Patient Questionnaire 571625 05/08 02/04/09
 
Helpful Documents:
Form Name HH DPC # Rev. Posted
A Guide to Parking at Hartford Hospital n/a 01/08 01/17/08
Patient Guide to Surgery 570186 03/05 12/01/06
Patient Guide to Diabetes Medications Before Surgery (English) 571140 12/07 02/12/08
Patient Guide to Diabetes Medications Before Surgery (Spanish) 571140 12/07 02/12/08
 
* These forms are provided in PDF format. When printing these forms, we suggest using a laser or other high-quality printer. In addition, please utilize the ORIGINALS, not copies. These steps will ensure bar codes are correctly interpreted by our document archival system.

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