Information for Physicians

Referrals

To refer a patient to the Hartford Hospital Comprehensive Liver Center complete the on-line referral form or call 860-972-4262.

Forms

The following forms are available for download (visit www.harthosp.org/forms for more forms):

• Ambulatory Record
• Authorization for Liver Transplant (English)
• Authorization for Liver Transplant (Spanish)
• Authorization for Surgery and/or Special Procedure/Treatment: Liver Transplant
• Authorization to Disclose Health Information (HH) (English)
• Authorization to Disclose Health Information (HH) (Spanish)
• Consent for Radiation Therapy (English)
• Consent for Radiation Therapy (Spanish)
• Informed Consent (English)
• Informed Consent (Spanish)
• Informed Consent for Liver Transplant Evaluation Process (English)
• Informed Consent for Liver Transplant Evaluation Process (Spanish)
• GI Pre-Procedure Orders
• Physician's Order Form
• Pre-Op Ambulatory Surgery
• Imaging Center Requisition
• Transplant Program - Liver Consult Referral Form
• Transplant Program Liver Pre-Transplant Health Questionnaire