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) 
• 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)
• 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)

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