The following forms* may be used when referring a patient to Hartford Hospital.
ADMISSION | CONSENT | PHYSICIAN'S ORDER | REFERRAL/REQUISITION | PATIENT QUESTIONNAIRES | MISC.
Arterial Catheter, Central Venous Catheter and Pulmonary Artery Catheter Placement and Replacement in the ICU
Bronchoscopy with or without Biopsy (English)
Bronchoscopy with or without Biopsy (Spanish)
Bronchoscopy (with or without Biopsy) in the ICU
Cataract Surgery With Intraocular Lens Implant (English)
Cataract Surgery With Intraocular Lens Implant (Spanish)
Colorectal Surgery (English)
Colorectal Surgery (Spanish)
Electroconvulsive (ECT) Treatment (English)
Electroconvulsive (ECT) Treatment (Spanish)
Flexible Fiberoptic Laryngoscopy
Left Ventricular Assist Device Insertion as Destination Therapy
Liver Transplant (English)
Liver Transplant (Spanish)
Lumbar Puncture (English)
Lumbar Puncture (Spanish)
Transcatheter Aortic Valve Replacement (TAVR)
Transfusion Blood/Blood Products (English)
Transfusion Blood/Blood Products (Spanish)
Nephrectomy Surgery (English)
Nephrectomy Surgery (Spanish)
Newborn Circumcision
Oral Surgery (English)
Oral Surgery (Spanish)
PICC or Midline Catheter
Heart Transplant (English)
Heart Transplant (Spanish)
Kidney Transplant - Recipient (English)
Kidney Transplant - Receptor (Spanish)
Laparoscopic Prostatectomy
Breast Surgery
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy
Diagnostic Arteriogram/Angiogram/Embolization (English)
Diagnostic Arteriogram/Angiogram/Embolization (Spanish)
Eye Surgery (English)
Eye Surgery (Spanish)
Image-guided Hemiogram (English)
Image-guided Hemiogram (Spanish)
Image-guided Paracentesis (English)
Image-guided Paracentesis (Spanish)
Image-guided Percutaneous Biopsy (English)
Image-guided Percutaneous Biopsy (Spanish)
Image-guided Thoracentesis (English)
Image-guided Thoracentesis (Spanish)
Liver Transplant
Open Heart Surgery Consent (English)
Open Heart Surgery Consent (Spanish)
Ovarian Vein Embolization (English)
Ovarian Vein Embolization (Spanish)
Pediatric Kidney Transplant (English)
Pediatric Kidney Transplant (Spanish)
Percutaneous Procedures (English)
Percutaneous Procedures (Spanish)
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (English)
Percutaneous Transhepatic Cholangiogram/Biliary Drainage/Stent Placement (Spanish)
Peripheral Angiography – Interventional (English)
Peripheral Angiography – Interventional (Spanish)
Spermatic Vein Embolization/Varicocele Treatment/Venogram (English)
Spermatic Vein Embolization/Varicocele Treatment/Venogram (Spanish)
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (English)
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (Spanish)
Uterine Artery Embolization for Fibroids (English)
Uterine Artery Embolization for Fibroids (Spanish)
Venous Access/Port (English)
Venous Access/Port (Spanish)
Consent for Radiation Therapy (English)
Consent for Radiation Therapy (Spanish)
Abdominal/Lower Back Area (English)
Abdominal/Lower Back Area (Spanish)
Brain (English)
Brain (Spanish)
Breast-Only Area (English)
Breast-Only Area (Spanish)
Breast Area and Adjacent Lymph Nodes (English)
Breast Area and Adjacent Lymph Nodes (Spanish)
Chest/Upper Back Area (English)
Chest/Upper Back Area (Spanish)
Chest Wall/Adjacent Lymph Nodes (English)
Chest Wall/Adjacent Lymph Nodes (Spanish)
Craniospinal Area (English)
Craniospinal Area (Spanish)
Extremities (English)
Extremities (Spanish)
Head and Neck Area (English)
Head and Neck Area (Spanish)
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (English)
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (Spanish)
Partial Breast Only (English)
Partial Breast Only (Spanish)
Prevention of Heterotopic Bone (English)
Prevention of Heterotopic Bone (Spanish)
Pelvic/Reproductive Organs (English)
Pelvic/Reproductive Organs (Spanish)
Pelvis Including Prostate (English)
Pelvis Including Prostate (Spanish)
Permanent, Interstitial Brachytherapy to the Prostate (English)
Permanent, Interstitial Brachytherapy to the Prostate (Spanish)
Vagina/Vaginal Cuff (English)
Vagina/Vaginal Cuff (Spanish)
Informed Consent (English)
Informed Consent (Spanish)
Informed Consent for Hemodialysis (English)
Informed Consent for Hemodialysis (Spanish)
Informed Consent for Liver Transplant Evaluation Process (English)
Informed Consent for Liver Transplant Evaluation Process (Spanish)
Informed Consent for Transcatheter Aortic Valve Replacement (TAVR)