Northwestern Memorial Hospital Physician Order Forms

Northwestern Memorial Hospital Physician Order Forms

Northwestern Memorial Hospital Physician Order Forms

Preoperative Clinic Forms for Physicians

The following forms provide all the necessary information physicians' offices will need to assist patients through the preoperative process.

  • Preoperative Clinic Health History Form (English | Spanish): Please complete or ask your patient to complete this health history form for ALL patients who will be having surgery or a procedure done at Northwestern Memorial Hospital. Fax this form to the eFax server at 312.926.9081.
  • Preoperative Clinic Order Form: If your patient will be having his/her preoperative evaluation done at the Northwestern Memorial Hospital (NMH) Preoperative Clinic, please complete this form and fax form to the eFax server at 312.926.9081. Please give the patient a copy of this completed form so that he/she may schedule their appointment.
  • Preoperative Clinic Triage Form: For your reference, you may use this form to determine the correct level of visit for the patient. The outpatient scheduling office (312.926.4566) will use this same triage form when your patient calls to make an appointment at the NMH Preoperative Clinic.
  • Minimum Surgical Blood Order Schedule: This is the Northwestern Memorial Hospital policy regarding minimal blood bank orders by procedure. You will find a comprehensive listing of surgical procedures with their requirements. Please note that the anesthesiologist on the day of surgery/procedure may not be able to proceed with the case until these requirements are met.
  • Patient Instructions for Surgery (English | Spanish): Should you wish, you can provide your patient with these instructions which provides detailed information for patients on how to prepare for their surgery or procedure at Northwestern Memorial Hospital.