NMH Preoperative Clinic Order Form

1 NMH Preoperative Clinic Order FormPATIENT INSTRUCTIONS - Scheduling a Preoperative Clinic appointmentCall 312-926-4566 to schedule an appointment with the Preoperative Clinic When you call, you will be informed whether you will need an appointment at the clinicOR a phone appointment with a nurse (based on your medical history and the surgery or procedure you will have)Please request an appointment date that is 4 to 21 days before your surgery or procedureThe Clinic is located at: 233 East Superior Street - 1st bring these 5 items to your appointment:This Order formYour current medical insurance cardA photo Your complete, up-to-date medication list (or all your medication bottles)Medical records, if available: lab results, ECG tracing, stress test, sleep study or recent note from your primary care doctor or cardiologistYou do not need to fast on the day of your visit unlessyour surgeon told you to do soSURGEON / OFFICE INSTRUCTIONS - Ordering tests and visitsPatient name (last, first): Patient DOB: Diagnosis/ICD-9: Planned procedure(s): Date of Procedure: Type of Anesthesia:1.

2 Select desired testing (check all that apply) :(All visits for testing will include a Clinic appointment with an RN, midlevel provider or physician - the PreoperativeClinic will determine the appropriate appointment type based on patient's medical history and planned procedure)No labs/X-rays or studies needed(patient to schedule a phone appointment with a Preoperative RN)Disease-based testing (Labs and ancillary studies will be ordered by the Preoperative Clinic based on the patient's medical history and anesthetic requirements for surgery or procedure. The Preoperative Clinic will follow up on results)Surgery-specific testing (Fill out below. The Preoperative Clinic will obtain tests, surgeonto follow up on results)Test name ICD-9 code (if different from above) Type & Screen Type & Cross (# of units) Autologous units 2. Select anticipated post op status: Inpatient23 hr On the Health History Form Page 2, did your patient check any medical condition within the boxed area?

3 YesN o4. Other orders: 5. Physician's Signature : Date:6. FAX this completed form to the Preoperative Clinic : 312-926-90817. Give the patient a copy of this form to schedule their appointment (Instructions at top of form)420640 (03/12)