Surgery Forms for Practices at UPMC in Central Pa.

Below are forms to be filled out prior to surgery in coordination with the patient and health care provider.

About your surgery guidebook for UPMC Carlisle, Community Osteopathic, Harrisburg, and West Shore (PDF)
About your surgery guidebook for UPMC Harrisburg, UPMC West Shore, UPMC Community Osteopathic, and UPMC Carlisle - Spanish (PDF)
About your surgery guidebook for UPMC Carlisle, Community Osteopathic, Harrisburg, and West Shore- Nepali (PDF)
About your surgery guidebook for UPMC Hanover (PDF)
About your surgery guidebook for UPMC Lititz (PDF)
About your surgery guidebook for UPMC Memorial (PDF)
Anesthesia Consent (PDF)
Blood Usage Schedule (PDF)
Consent or Refusal for Administration of Blood and Blood Components (PDF)
Consent for Circumcision (PDF)
Consent for Sterilization (Operation and Anesthetic) (PDF)
Consent for Sterilization (Spanish) (PDF)
Consentimiento Informado Para Administración De Sangre Y Componentes De La Sangre (PDF)
Consent for Operation Diagnostic and Therapeutic Procedures and Anesthesia (PDF)
Consentimiento Para La Operacion, Procedimientos Terapeuticos Y De Diagnostico Y Anestesia (PDF)
Consent for Treatment of a Minor (PDF)
ERAS Patient Brochure (PDF)
Inpatient History and Physical Examination (PDF)
Ortho/Spine Chlorhexidine Information Sheet (PDF)
Outpatient History and Physical (PDF)
Patient Education: Enhanced Recovery after Surgery(ERAS) Chlorhexidine Soap (PDF)
Patient Education Ensure Pre-Surgery (PDF)
Patient Education Gatorade G2 (PDF)
Patient Education for Pregnancy Testing (Spanish Version) Prueba De Embarazo Antes De Su Procedimiento (PDF)
Preadmission Testing Worksheet with Recommendations (PDF)
Practice Order Sheet-UPMC (PDF)
Pre-surgery Nutritional Education-Obesity (PDF)
Pre-surgery Nutritional Education-High Protein (PDF)
Request for H&P Clinic Appointment (PDF)
Request for Pre-Surgical Optimization (PDF)
Your Guide to Optimization (PDF)

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