The following forms* may be used when referring a patient to Hartford Hospital.

ADMISSION | CONSENT | PHYSICIAN'S ORDER | REFERRAL/REQUISITION | PATIENT QUESTIONNAIRES | MISC.

 
Admission Forms:
 
Consent Forms:
Form Name HH-DPC# Rev. Posted
Authorization For...      
Arterial Catheter, Central Venous Catheter and Pulmonary Artery Catheter Placement and Replacement in the ICU
 571330 01/10 09/20/11
Bronchoscopy with or without Biopsy (English)
 572095 08/11 08/26/11
Bronchoscopy with or without Biopsy (Spanish)
 572125
08/11 08/26/11
Bronchoscopy (with or without Biopsy) in the ICU
 571331 07/11 07/26/11
Cataract Surgery With Intraocular Lens Implant (English)
 572141 08/11 08/29/11
Cataract Surgery With Intraocular Lens Implant (Spanish)
 572142 08/11 08/29/11
Colorectal Surgery (English)
 577125 11/11 12/19/11
Colorectal Surgery (Spanish)
 577200 12/11 12/19/11
Electroconvulsive (ECT) Treatment (English)
 577195 08/11 08/08/11
Electroconvulsive (ECT) Treatment (Spanish)
 577205 08/11 08/08/11
Flexible Fiberoptic Laryngoscopy
577211
 11/11
 11/29/11
Left Ventricular Assist Device Insertion as Destination Therapy
 577165 11/11 11/16/11
Liver Transplant (English)
 572112 12/11 12/21/11
Liver Transplant (Spanish)
 572212 01/11 01/19/11
Lumbar Puncture (English)
 572039 05/11 06/17/11
Lumbar Puncture (Spanish)
 572039-SP 05/11 06/17/11
Transcatheter Aortic Valve Replacement (TAVR)
577143 01/12
 02/03/12
Transfusion Blood/Blood Products (English)
 577090 08/11 08/29/11
Transfusion Blood/Blood Products (Spanish)
 577092 08/11 08/29/11
Nephrectomy Surgery (English)
 572153 09/11 09/09/11
Nephrectomy Surgery (Spanish)
 572153-SP 10/11 11/02/11
Newborn Circumcision
 577103 04/11 04/19/11
Oral Surgery (English)
577088 12/11 12/05/11
Oral Surgery (Spanish)
577094 12/11 12/05/11
PICC or Midline Catheter
 571310
 11/11
 11/21/11
Authorization for Surgery...      
Heart Transplant (English)
 577010 12/11 12/22/11
Heart Transplant (Spanish)
 577210 01/11 01/19/11
Kidney Transplant - Recipient (English)
 577192 01/11 01/24/11
Kidney Transplant - Receptor (Spanish)
 577202 01/11 01/19/11
Laparoscopic Prostatectomy
 577164 09/10 02/10/11
Authorization for Surgery and/or Special Procedure/Treatment...      
Breast Surgery
 572300
04/11 04/19/11
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy
 577080 08/11 08/26/11
Diagnostic Arteriogram/Angiogram/Embolization (English)
 577123 11/11 11/21/11
Diagnostic Arteriogram/Angiogram/Embolization (Spanish)
 577163 11/11 11/21/11
Eye Surgery (English)
 572253 01/11 03/25/11
Eye Surgery (Spanish)
 572267 02/11 03/24/11
Image-guided Hemiogram (English)
 577120 11/11 11/21/11
Image-guided Hemiogram (Spanish)
 577160 11/11 11/21/11
Image-guided Paracentesis (English)
 577119 11/11 11/21/11
Image-guided Paracentesis (Spanish)
 577159 11/11 11/21/11
Image-guided Percutaneous Biopsy (English)
 577122 11/11 11/21/11
Image-guided Percutaneous Biopsy (Spanish)
 577122-SP 11/11 11/21/11
Image-guided Thoracentesis (English)
 577118 11/11 11/21/11
Image-guided Thoracentesis (Spanish)
 577158 11/11 11/21/11
Liver Transplant
577009 12/11 12/21/11
Open Heart Surgery Consent (English)
 577070 12/11
 12/19/11
Open Heart Surgery Consent (Spanish)
 577071 12/11 12/19/11
Ovarian Vein Embolization (English)
 577121 11/11 11/21/11
Ovarian Vein Embolization (Spanish)
 577161 11/11 11/21/11
Pediatric Kidney Transplant (English)
 577040 05/11 05/20/11
Pediatric Kidney Transplant (Spanish)
 577040-SP 05/11 05/20/11
Percutaneous Procedures (English)
 577005 11/11 11/21/11
Percutaneous Procedures (Spanish)
 577005-SP 11/11 11/21/11
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (English)
 577006 11/11 11/21/11
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (Spanish)
 577027 11/11 11/21/11
Peripheral Angiography – Interventional (English)
 577012 11/11 11/21/11
Peripheral Angiography – Interventional (Spanish)
 577018 11/11
11/21/11
Spermatic Vein Embolization/Varicocele Treatment/Venogram (English)
 577116 11/11 11/23/11
Spermatic Vein Embolization/Varicocele Treatment/Venogram (Spanish)
 577156 11/11 11/23/11
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (English)
 577004 11/11 11/28/11
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (Spanish)
 577019 11/11 11/28/11
Uterine Artery Embolization for Fibroids (English)
 577002
 11/11
 11/21/11
Uterine Artery Embolization for Fibroids (Spanish)
 577029
 11/11
 11/21/11
Venous Access/Port (English)
 577003 11/11
 11/21/11
Venous Access/Port (Spanish)
 577017 11/11 11/21/11
Authorization to Disclose Health Information (HH) (English) 571559 08/11 08/12/11
Authorization to Disclose Health Information (HH) (Spanish) 571825 08/11 08/12/11
Authorization to Disclose Health Information (IOL) (English) 573008 08/11 08/12/11
Authorization to Disclose Health Information (IOL) (Spanish) 571826 08/11 08/12/11
Bloodless Medicine & Surgery - Advance Directive (English & Spanish) 571041 01/11 02/08/11
Bloodless Medicine & Surgery - Refusal of Blood Transfusion/Minors (English & Spanish) 571157 01/11 01/28/11
Bloodless Medicine & Surgery - Release Form (English & Spanish) 571158 01/11
 03/04/11
Consent for Acceptance of Liver Allograft (English) 577054 01/12
 01/30/12
Consent for Acceptance of Liver Allograft (Spanish) 577054-SP 01/12 01/30/12
Consent for Radiation Therapy...      
Consent for Radiation Therapy (English)
 577145 08/10 01/27/11
Consent for Radiation Therapy (Spanish)
 577187
 11/10
 12/14/10
Abdominal/Lower Back Area (English)
 577131 06/10 01/27/11
Abdominal/Lower Back Area (Spanish)
 577151
 11/10
 12/14/10
Brain (English)
 577132 06/10 03/24/11
Brain (Spanish)
 577152 11/10 03/24/11
Breast-Only Area (English)
 577135 08/10 01/27/11
Breast-Only Area (Spanish)
 577181 11/10 12/14/10
Breast Area and Adjacent Lymph Nodes (English)
 577134 08/10 01/27/11
Breast Area and Adjacent Lymph Nodes (Spanish)
 577184 11/10 12/14/10
Chest/Upper Back Area (English)
 577136 08/10 01/27/11
Chest/Upper Back Area (Spanish)
 577182 11/10
 12/14/10
Chest Wall/Adjacent Lymph Nodes (English)
 577137
 08/10
 01/27/11
Chest Wall/Adjacent Lymph Nodes (Spanish)
 577183 11/10
 12/14/10
Craniospinal Area (English)
 577138 08/10 01/27/11
Craniospinal Area (Spanish)
 577185 11/10
 12/14/10
Extremities (English)
 577139 08/10 01/27/11
Extremities (Spanish)
 577186 11/10 12/14/10
Head and Neck Area (English)
 577146 08/10 02/08/11
Head and Neck Area (Spanish)
 577188 11/10 12/14/10
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (English)
 572131 02/11 03/21/11
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (Spanish)
 572131-SP 02/11 04/15/11
Partial Breast Only (English)
 572132 02/11 03/11/11
Partial Breast Only (Spanish)
 572132-SP 02/11 04/15/11
Prevention of Heterotopic Bone (English)
 577147 08/10 02/08/11
Prevention of Heterotopic Bone (Spanish)
 577189 11/10 12/14/10
Pelvic/Reproductive Organs (English)
 572145 06/11 06/17/11
Pelvic/Reproductive Organs (Spanish)
 572145-SP 06/11 06/17/11
Pelvis Including Prostate (English)
 577133 06/10 01/27/11
Pelvis Including Prostate (Spanish)
 577153 11/10 12/14/10
Permanent, Interstitial Brachytherapy to the Prostate (English)
577148 08/10 02/08/11
Permanent, Interstitial Brachytherapy to the Prostate (Spanish)
577180 11/10 12/14/10
Vagina/Vaginal Cuff (English)
 577130 06/10 01/27/11
Vagina/Vaginal Cuff (Spanish)
 577150 11/10 12/14/10
Consent for Deceased Donor Liver Transplant 577058 12/11 12/19/11
Consent to Photography (for purposes of treatment - English) 571940 01/08 01/18/11
Consent to Photography (for purposes of treatment - Spanish) 572140 01/11 01/17/11
Consent to Transfer (EMTALA Consents) as Recommended by Provider 571670
 01/12
 01/24/12
Hartford Hospital Dialysis Patient/Dialysis Treatment Facility Agreement (English) 571742 03/11
 03/24/11
Hartford Hospital Dialysis Patient/Dialysis Treatment Facility Agreement (Spanish) 571742-SP 03/11
 03/24/11
Hartford Hospital/CT Children's Medical Center Combined Consent Form (English & Spanish)
 571097 03/11 03/24/11
Informed Consent...
      
Informed Consent (English)
 571084 11/11 11/21/11
Informed Consent (Spanish)
 571127 11/11 11/21/11
Informed Consent for Hemodialysis (English)
 571514 03/11 03/24/11
Informed Consent for Hemodialysis (Spanish)
 571514-SP 03/11 03/24/11
Informed Consent for Liver Transplant Evaluation Process (English)
 577056 11/11 01/19/12
Informed Consent for Liver Transplant Evaluation Process (Spanish)
 577056-SP 12/11 01/19/12
Informed Consent for Transcatheter Aortic Valve Replacement (TAVR)
 577144
 01/12
 02/03/12
Media Consent (English) 570631 05/11 05/06/11
Media Consent (Spanish) 570631-SP 05/11 05/06/11
 
Physician's Order Forms:
Form Name HH-DPC# Rev. Posted
Antineoplastic Drug Order Form 570060 05/11 05/06/11
C8 Admission Orders 549429 12/11 12/13/11
Colorectal Surgical Admission Orders 549328A 08/11 10/04/11
Laparoscopic Cholecystectomy Surgical Admission Orders 549328C 09/11 09/20/11
DNR Inpatient Order 571504 05/10 09/17/10
Eye Surgery Center Physician Order Form 572261 06/11 08/03/11
Eye Surgery Center Physician Order Form - Intraocular 572260 11/11 11/15/11
GI Pre-Procedure Orders 549382A 08/05 04/19/10
Gynecology/Oncology MD Orders 549006 08/11 08/10/11
Hemo/Oncology Physician Order 546820 03/10 10/05/10
Pacemaker and ICD Placement and EP/Ablation Hospital Level of Care Checklist 572122 12/10 02/10/11
Physician's Order Form 546808 04/11
04/12/11
Pre-Op Ambulatory Surgery 549438 06/10 07/25/11
Pre-Op Bariatric Surgery 549422 10/11
 11/02/11
Pre-Op Laproscopic Cholecystectomy 549328C 01/09 02/04/09
Pre-Op Lumbar Fusion 549316 01/09 02/04/09
Pre-Op Total Joint 546808D 05/10 08/30/10
Pre-Op Open Heart 549460 05/08 11/20/09
Pre-Op Lapropscopic Nissen Fundoplication/Heller Myotomy 549437 01/09 02/04/09
Robotic Prostatectomy Orders 549463 10/05 10/18/10
Transfusion Services Orders 549005 06/07 04/19/10
Vancomycin Order and Rationale 549007 09/07 10/05/10
West Hartford Surgery Center - Peri-Operative Orders 578021 08/11
09/26/11
Women's Health Services Admission Orders 549487 07/11 07/26/11
Women's Health Services Pre-Op Ambulatory Surgery Orders 549488 07/11 07/26/11
 
Referral/Requisition Forms:
Form Name HH-DPC# Rev. Posted
Cardiac Rehabilitation Referral 571979 12/08 02/11/09
Consultant Preferences for Hospitalist Care n/a 08/10 08/06/10
Diabetes LifeCare - Consult for Surgical Weight Loss Patient 572025 06/10 12/23/10
Diabetes LifeCare - Plan of Care 571780 09/08 08/10/09
Diabetes LifeCare - Plan of Care (for pregnant patients only) 571448 09/08 08/10/09
Electromyography (EMG) Laboratory Referral 571152 10/11 10/11/11
Hereditary Cancer Risk Assessment Provider Referral Fax Notification (English) 571807 11/09 01/14/10
Hereditary Cancer Risk Assessment Provider Referral Fax Notification (Spanish) 571783 09/09 01/14/10
Imaging Center Requisition 546231 01/10 06/24/10
Request for Non-Invasive Cardiology Evaluation 571882 10/11
 10/20/11
Request for Outpatient Echocardiography Evaluation 546579 10/11 10/18/11
Sleep Disorder Center Referral Form 571922
 10/09 01/11/10
Transplant Program - Liver Consult Referral Form 572043 01/11 01/28/11
 
Patient Questionnaires:
Form Name HH-DPC# Rev. Posted
Diabetes LifeCare Program - Patient Questionnaire 570307 08/08 08/10/09
Diabetes LifeCare Program - Prenatal Patient Questionnaire 571102 04/07 08/10/09
Dizziness Questionnaire for the Hartford Hospital Balance Clinic 571461 01/11 01/25/11
Patient Pre-Admission Questionnaire (English) 571094 04/11 07/26/11
Patient Pre-Admission Questionnaire (Spanish) 571094-SP 04/11 07/26/11
Patient Pre-Admission Questionnaire - West Hartford Surgery Center 578028
 10/11 11/01/11
Transplant Program Kidney Donor Registration Form n/a n/a 01/05/11
Transplant Program Kidney Donor History & Health Questionnaire n/a 11/10 01/05/11
Transplant Program Kidney Donor Nutrition Questionnaire n/a n/a 01/05/11
Transplant Program Liver Pre-Transplant Health Questionnaire
 n/a
 02/08
 01/06/11
Transplant Program Downtime Questionnaire n/a 02/08 01/06/11
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
 
Miscellaneous Documents/Forms:
* 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.