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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.

  • Anesthesia Consent (PDF)
  • Anesthesia Testing Guidelines (PDF)
  • Blood Usage Schedule (PDF)
  • Chlorhexidine (Spanish) (PDF)
  • Chlorhexidine Information Sheet (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)
  • Diabetes Medicines Before Surgery - Patient Education (PDF)
  • ERAS Patient Brochure (PDF)
  • ERAS Enhanced Recovery After Surgery Booklet (Central Pa.) - Spanish (PDF)
  • Inpatient History and Physical Examination (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)
  • Recuperación mejorada después de la cirugía (ERAS) con jabón de clorhecidina (PDF)
  • Request for H&P Clinic Appointment (PDF)
  • Request for Pre-Surgical Optimization (PDF)
  • Surgery Center/Carlisle Informed Consent to Operation, Diagnostic and Therapeutic Procedures, and Anesthesia (PDF)
  • Total Joint Replacement Guidebook for Central PA (PDF)
  • Your Guide to Optimization (PDF)

Anterior Cervical Discectomy With or Without Stabilization Consent (PDF)

Lumbar Decompression With or Without Stabilization Consent (PDF)

Lumbar or Thoracic Posterior Microdiscectomy Consent (PDF)

Posterior Cervical Decompression With or Without Stabilization Consent (PDF)

Surgery Special Procedure Consent (PDF)

 

 

 

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