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:
Form Name HH-DPC# Rev. Posted
Ambulatory Record 571099 08/12 09/11/12
Brain Death (Adults) Progress Note 571120 03/12 04/24/13
Brain Death (Children) Progress Note 572028 04/13 04/24/13
Cardiac Surgery Consult for Surgical Evaluation 571890 11/13 01/07/14
Cardiology PC - Consultation/Admission Report 571845 05/08 09/23/08
Elective Admission/Surgery H&P Form 571048 10/12 10/11/12
Eye Surgery Center - Eye History & Physical 572264 06/11 08/03/11
Eye Surgery Center - History & Physical 578038 06/11 08/03/11
Eye Surgery Center - Laser Procedure Room Documentation 572262 09/11 10/18/11
Neurology - Admission History and Physical - Stroke/TIA 572105 05/11 07/26/11
Neurology - Admission History and Physical - Intracerebral Hemorrhage 572107 05/11 07/26/11
Neurology - Initial Evaluation/Consultation 572106 05/11 07/26/11
Re-Assessment History & Physical Form 571065 05/10 11/02/12
West Hartford Surgery Center - History & Physical 578024 08/11 08/25/11
 
Consent Forms:
Form Name HH-DPC# Rev. Posted
Authorization For...      
Generic Informed Consent (English)
571084 11/11 11/21/11
Generic Informed Consent (Spanish)
571127 11/11 11/21/11
Anterior Cervical Discectomy
577171 01/12 02/20/12
Arterial Catheter, Central Venous Catheter and Pulmonary Artery Catheter Placement and Replacement in the ICU
571330 01/10 09/20/11
Audio/Video EEG Monitoring (English/Spanish)
571024 01/13
01/09/13
Bloodless Medicine & Surgery - Advance Directive (English & Spanish)
571041 10/13 02/04/14
Bloodless Medicine & Surgery - Refusal of Blood Transfusion/Minors (English & Spanish)
571157 03/14 04/29/14
Bloodless Medicine & Surgery - Release Form (English & Spanish)
571158 05/12 10/05/12
Bloodless Medicine & Surgery - Revocation of Refusal of Blood and Blood Derivatives (English & Spanish)
571705 03/14
04/29/14
Breast Surgery
572300 12/12 12/17/12
Breast Surgery (Spanish)
572300-SP
06/12
06/27/12
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
Cardiac Catheterization/Percutanous Coronary Interventions (English)
577013 11/12 12/17/12
Cardiac Catheterization/Percutanous Coronary Interventions (Spanish)
577013-SP 11/12 11/21/12
Cataract Surgery With Intraocular Lens Implant (English)
572251 03/12 03/19/12
Cataract Surgery With Intraocular Lens Implant (Spanish)
572251-SP 03/12 03/19/12
CCMC/Hartford Hospital Combined Consent Form (English & Spanish)
571097 03/11 03/24/11
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy
577080 05/14 06/17/14
Colonoscopy/Endoscopy/Sigmoidoscopy/Polypectomy with Fecal Transfer
577080A 05/14 06/17/14
Colorectal Surgery (English)
577125 10/12 12/20/12
Colorectal Surgery (Spanish)
577200 06/12 11/01/12
Colposcopy with Cervical biopsies and Local Excisions
577230 10/12
11/01/12
Consent to Transfer (EMTALA Consents) as Recommended by Provider
571670 01/12 01/24/12
Continuous Veno-Venous Hemodialysis
577252 04/14 06/17/14
Craniotomy
577172 01/12 02/10/12
Cystectomy (English)
577220 10/12 10/09/12
Cystectomy (Spanish)
577220-SP 10/12 10/11/12
Dialysis Patient/Dialysis Treatment Facility Agreement (English)
571742 03/11 03/24/11
Dialysis Patient/Dialysis Treatment Facility Agreement (Spanish)
571742-SP 06/12 07/12/12
Electroconvulsive (ECT) Treatment (English)
577195 08/11 08/08/11
Electroconvulsive (ECT) Treatment (Spanish)
577205 08/11 08/08/11
Electrophysiology/Arrhythmia Services (Invasive)
577110 11/12
11/27/13
Electrophysiology/Arrhythmia Services (Non-Invasive)
577110-A 11/13 11/27/13
Endometrial Biopsy and/or Sonohysterogram
577227
10/12
11/01/12
EP Study with Mapping and Ablation (English)
577016
11/12 11/21/12
EP Study with Mapping and Ablation (Spanish)
577016-SP 11/12 11/21/12
ERCP/Endoscopic Ultrasound (English)
577082
12/12
12/17/12
ERCP/Endoscopic Ultrasound (Spanish)
577083 02/13
02/19/13
Eye Center Surgery and/or Special Procedure/Treatment
572253 05/11 05/23/12
Extracorporeal Membrane Oxygenation (ECMO)
577248 04/14 06/18/14
Flexible Fiberoptic Laryngoscopy
577211 11/11 11/29/11
Genetic Amniocentesis
572024 02/12 03/01/12
Hemodialysis (English)
571514 03/11 07/12/12
Hemodialysis (Spanish)
571514-SP 03/11 03/24/11
Hereditary Cancer Genetic Testing, General (English)
571325 10/12
10/04/12
Hereditary Cancer Genetic Testing, General (Spanish)
571325-SP
10/12
11/01/12
Hereditary Cancer Genetic Testing for APC and MYH (English)
571326 10/12 10/04/12
Hereditary Cancer Genetic Testing for APC and MYH (Spanish)
571326-SP 10/12
11/01/12
Hereditary Cancer Genetic Testing for BRCA1 and BRCA2 (English)
571327 10/12 10/04/12
Hereditary Cancer Genetic Testing for BRCA1 and BRCA2 (Spanish)
571327-SP 10/12
11/01/12
Hereditary Cancer Genetic Testing for Lynch Syndrome (English)
571328 10/12
10/04/12
Hereditary Cancer Genetic Testing for Lynch Syndrome (Spanish)
571328-SP 10/12 11/01/12
Hernia Center: Inguinal Hernia Repair
577222 07/12
10/05/12
Hernia Center: Ventral Hernia Repair
577224 08/12 10/05/12
Hyperbaric Oxygen
571636 06/12
10/11/12
Hysterectomy (English)
577022
11/12 11/21/12
Hysterectomy (Spanish)
577022-SP 11/12 11/21/12
Insertion/Removal of Implanon/Nexplanon
577228
10/12
11/01/12
Infant Drug Screening (English/Spanish)
577232 12/12 01/09/13
Intrauterine Device Insertion and/or Removal (English/Spanish)
577231 12/12 01/09/13
Laparoscopic Cholecystectomy
577223 08/12
10/05/12
Laparoscopic Hysterectomy
577250 04/14
06/17/14
Laparoscopic Myomectomy
577249 04/14
06/17/14
Laparoscopic Nissen Fundoplication/Paraesophageal Hernia Repair
577225 08/12 10/05/12
Laparoscopic Prostatectomy
577164 11/12 11/08/12
LDL Apheresis
572077 12/12 12/17/12
Left Ventricular Assist Device Insertion as Destination Therapy
577165 03/14 03/17/14
Loop Electrical Excision Procedure of the Cervix
577229
10/12
11/01/12
Lumbar Discectomy
577174 02/12 02/17/12
Lumbar Puncture (English & Spanish)
572039 11/12 11/08/12
Lumbar Spinal Fusion
577173 01/12 02/10/12
MitralClip Procedure
577246 03/14 06/17/14
Medications Not Positively Identified
577213 04/12 04/30/12
Nephrectomy Surgery (English)
572153 09/11 09/09/11
Nephrectomy Surgery (Spanish)
572153-SP 10/11 11/02/11
Newborn Circumcision (English)
577103 06/12 07/23/12
Newborn Circumcision (Spanish)
577104 11/01 10/19/12
Open Heart Surgery (English)
577070 12/11 12/19/11
Open Heart Surgery (Spanish)
577071 12/11 12/19/11
Oral Surgery (English)
577088 12/11 12/05/11
Oral Surgery (Spanish)
577094 12/11 12/05/11
Ovarian Vein Embolization (English)
577121 11/11 11/21/11
Ovarian Vein Embolization (Spanish)
577161 11/11 11/21/11
Pacemaker/AICD (Automatic Cardioverter Defibrillator) (English)
577000 11/12 11/21/12
Pacemaker/AICD (Automatic Cardioverter Defibrillator) (Spanish)
577000-SP 11/12 11/21/12
Percutaneous Gastrotomy/Jejunostomy
577214 04/12 07/12/12
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)
571134 02/13 02/14/13
Peripheral Angiography – Interventional (Spanish)
577018 11/12 11/08/12
PICC or Midline Catheter
571310 11/11 11/21/11
Radiation Therapy Consents:
     
Consent for Radiation Therapy (English)
577145 05/12 05/31/12
Consent for Radiation Therapy (Spanish)
577187 05/12 05/31/12
Abdominal/Lower Back Area (English)
577131 05/12 05/31/12
Abdominal/Lower Back Area (Spanish)
577151 05/12 05/31/12
Brain (English)
577132 06/10 05/30/12
Brain (Spanish)
577152 11/10 05/30/12
Breast-Only Area (English)
577135 12/12 01/09/13
Breast-Only Area (Spanish)
577135-SP 02/13 02/14/13
Breast Area and Adjacent Lymph Nodes (English)
577134 12/12 01/09/13
Breast Area and Adjacent Lymph Nodes (Spanish)
577184 05/12 06/01/12
Chest/Upper Back Area (English)
577136 05/12 06/01/12
Chest/Upper Back Area (Spanish)
577182 05/12 06/01/12
Chest Wall/Adjacent Lymph Nodes (English)
577137 05/12 05/31/12
Chest Wall/Adjacent Lymph Nodes (Spanish)
577183 05/12 05/31/12
Craniospinal Area (English)
577138 05/12 05/31/12
Craniospinal Area (Spanish)
577185 05/12 05/31/12
Extremities (English)
577139 05/12 06/01/12
Extremities (Spanish)
577186 05/12 06/01/12
Head and Neck Area (English)
577146 05/12 06/01/12
Head and Neck Area (Spanish)
577188 05/12 06/01/12
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (English)
572131 05/12 06/01/12
Hodgkin's/Non-Hodgkin's Lymphoma Mantle (Spanish)
572131-SP 05/12 06/01/12
Partial Breast Only (English)
572132 12/12 01/09/13
Partial Breast Only (Spanish)
572132-SP 05/12 06/01/12
Prevention of Heterotopic Bone (English)
577147 05/13 06/11/12
Prevention of Heterotopic Bone (Spanish)
577189 05/12 06/01/12
Pelvic/Reproductive Organs (English)
572145 05/12 06/01/12
Pelvic/Reproductive Organs (Spanish)
572146 05/12 06/01/12
Pelvis Including Prostate (English)
577133 05/12 05/31/12
Pelvis Including Prostate (Spanish)
577153 05/12 05/31/12
Permanent, Interstitial Brachytherapy to the Prostate (English)
577148 05/12 05/31/12
Permanent, Interstitial Brachytherapy to the Prostate (Spanish)
577180 05/12 05/31/12
Ra223
577241 01/14 06/18/14
SM-153
577239 01/14
06/18/14
Vagina/Vaginal Cuff (English)
577130 04/12 05/09/12
Vagina/Vaginal Cuff (Spanish)
577150 04/12 05/30/12
Y-90 Zevalin
577240 01/14 06/18/14
Radiology Consents:
     
Diagnostic Arteriogram/Angiogram/Embolization (English)
577123 11/11 11/21/11
Diagnostic Arteriogram/Angiogram/Embolization (Spanish)
577163 11/11 11/21/11
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 03/01/12
Image-guided Paracentesis (Spanish)
577159 11/11 03/01/12
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
Right Heart Catheterization/Right Ventricular Biopsy (English)
577166 02/12 03/09/12
Right Heart Catheterization/Right Ventricular Biopsy (Spanish)
577166-SP 02/12 03/09/12
Roux-en-Y Gastric Bypass
577034 11/12 12/17/12
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
Surgical Tracheostomy
577236 06/14 06/17/14
Therapeutic Plasma Exchange (TPE)
577251 04/14 06/17/14
Thyroid/Parathyroad Surgery
577226 10/12 10/29/12
Transcatheter Aortic Valve Replacement (TAVR)
577143 02/12 02/29/12
Transcatheter Aortic Valve Replacement (TAVR) Supplement
577144 01/12 02/08/12
Transesophageal Echocardiogram
577254 07/14 09/23/14
Transesophageal Echocardiogram with Cardioversion (English)
577255 07/14
09/23/14
Transesophageal Echocardiogram with Cardioversion (Spanish)
577255-SP
07/14
09/23/14
Transfusion Blood/Blood Products (English)
577090 08/11 08/29/11
Transfusion Blood/Blood Products (Spanish)
577092 11/12 11/21/12
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (English)
577004 11/11 11/28/11
Transjugular Intrahepatic Portosystemic Shunt (TIPS) (Spanish)
577019 11/11 11/28/11
Transplant Consents:



Heart Transplant (English)
577010 04/14 04/15/14
Heart Transplant (Spanish)
577010-SP
01/14 08/06/14
Heart Transplant Recipient Informed Consent (English)
577048 06/13 02/21/14
Heart Transplant - Consent for Deceased Heart Donor Organ Options (English)
577052 01/14 02/03/14
Heart Transplant - Consent for Deceased Heart Donor Organ Options (Spanish)
577052-SP
01/14 02/21/14
Kidney Transplant - Consent for Deceased Kidney Donor Organ Options (English)
577068 01/14 02/03/14
Kidney Transplant - Consent for Deceased Kidney Donor Organ Options (Spanish)
577068-SP 01/14 02/21/14
Kidney Transplant - Consent for Transplant Evaluation Process
577126 03/12 04/13/12
Kidney Transplant - Living Kidney Donation
577042 08/12 10/05/12
Kidney Transplant - Living Kidney Donation (Spanish)
577042-SP 10/12 10/11/12
Kidney Transplant - Recipient (English)
577192 01/14 02/21/14
Kidney Transplant - Recipient (Spanish)
577192-SP 01/14 02/21/14
Liver Transplant (English)
572112 01/14 02/03/14
Liver Transplant (Spanish)
572212-SP 01/14 02/21/14
Liver Transplant Program - Liver Allograft (English)
577054 01/14 02/03/14
Liver Transplant Program - Liver Allograft (Spanish)
577054-SP 01/14 02/21/14
Liver Transplant Program - Evaluation Process (English)
577056 11/11 01/19/12
Liver Transplant Program - Evaluation Process (Spanish)
577056-SP 12/11 01/19/12
Urine Drug Screening (English/Spanish)
577233 12/12 01/09/13
Uterine Artery Embolization for Fibroids (English)
577002 02/13 03/01/13
Uterine Artery Embolization for Fibroids (Spanish)
577029 04/13 04/29/13
Venous Access/Port (English)
577003 12/12 01/09/13
Venous Access/Port (Spanish)
577017 11/11 11/21/11
Wound Debridement
571638 11/12 11/08/12
Photography/Media      
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
Media Consent (English)
570631 05/11 05/06/11
Media Consent (Spanish)
570631-SP 05/11 05/06/11
Release of Medical Records      
Authorization to Disclose Health Information (HH) (English)
571559 02/13 02/06/13
Authorization to Disclose Health Information (HH) (Spanish)
571825 05/12 06/22/12
Authorization to Disclose Health Information (IOL) (English)
573008 05/12 06/22/12
Authorization to Disclose Health Information (IOL) (Spanish)
571826 05/12 06/22/12
 
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
Cisplatin HIPEC Order Form 549556 07/14 08/07/14
Colorectal Surgical Admission Orders 549328A 02/13 03/05/13
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 Endoscopy Order Set 549386 12/12
01/29/13
GI Pre-Procedure Orders 549382A 08/05 04/19/10
Gynecology INTRA-OP Orders 571091 01/12 02/29/12
Gynecology/Oncology MD Orders 549006 02/12 11/30/12
Hemo/Oncology Physician Order 546820 03/10 10/05/10
Mitomycin HIPEC Order Form 549555 07/14
08/07/14
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 02/13 05/02/13
Women's Health Services Admission Orders 549487 06/12 10/11/12
Women's Health Services Pre-Op Ambulatory Surgery Orders 549488 06/12 10/11/12
 
Referral/Requisition Forms:
Form Name HH-DPC# Rev. Posted
Cardiac Rehabilitation Referral 571979 05/14 05/28/14
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
EEG Laboratory Outpatient Referral Form 546371 02/13 02/20/14
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 09/12 11/28/12
Request for Non-Invasive Cardiology Evaluation 571882 05/14 05/22/14
Request for Outpatient Echocardiography Evaluation 546579 05/14 05/22/14
Sleep Disorder Center Referral Form 571922 07/12 08/30/12
Transplant Program - Liver Consult Referral Form 572043 01/11 01/28/11
 
Patient Questionnaires:
Form Name HH-DPC# Rev. Posted
Central Connecticut Cystic Fibrosis Center Clinic Visit Treatment Record 571053 09/13 08/22/14
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 Liver Pre-Transplant Surgical Consult 572217 03/12
04/06/12
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.