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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 | PHYSICIAN'S ORDER | REFERRAL/REQUISITION | PATIENT QUESTIONNAIRES | MISCELLANEOUS

 
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
Authorization to Disclose Health Information (HH) (English) 571559 08/06 07/23/09
Authorization to Disclose Health Information (HH) (Spanish) 571825 08/06 07/23/09
Authorization to Disclose Health Information (IOL) (English) 573008 08/06 07/23/09
Authorization to Disclose Health Information (IOL) (Spanish) 571826 08/06 07/23/09
Cardiology PC - Consultation/Admission Report 571845 05/08 09/23/08
Elective Admission/Surgery H&P Form 571048 12/09 01/13/10
Informed Consent (English) 571084 07/08 09/11/09
Informed Consent (Spanish) 571127 07/07 09/11/09
Inpatient Admission H&P Form 546812 09/09 01/08/10
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 07/08 09/01/09
 
Physician's Order Forms:
Form Name HH-DPC# Rev. Posted
C8 Admission Orders 549429 10/07 09/01/09
Gynecology/Oncology MD Orders 549006 09/07 02/02/10
Pre-Op Ambulatory Surgery 549438 05/09 09/01/09
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 05/08 11/20/09
Pre-Op Lapropscopic Nissen Fundoplication/Heller Myotomy 549437 01/09 02/04/09
 
Referral/Requisition Forms:
 
Patient Questionnaires:
 
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.
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