Patient Questionnaires

Miscellaneous Documents/Forms

Form Name HH-DPC# Rev. Posted
COVID-19 Vaccination Clinical Consent & Authorization for Disclosure 577653 08/21 04/06/22
Diabetes Service Nurse Practitioner Follow-Up 572306 08/13 09/30/13
Hartford Hospital "DO NOT USE" Abbreviations n/a 12/03 11/24/10
Pain Treatment Center New Patient Consult n/a 05/14 05/08/14
Pain Treatment Center Progress Note n/a 05/14 05/08/14
Patient Guide to Surgery 570186 03/05 12/01/06
Patient Guide to Diabetes Medications Before Surgery (English) 571140 12/07 02/12/08
Patient Guide to Diabetes Medications Before Surgery (Spanish) 571140 12/07 02/12/08
Transplant Program Medication Renewal/Request List n/a n/a 01/06/11
Trauma Progress Note 571588 09/11 03/13/12
Trauma Supplemental Resuscitation Record 571138 11/11 03/13/12
Trauma Tertiary Survey 571916 10/11 03/13/12

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.