Surgical Services Forms

Patient Information Forms

Name	Number	Language
Orthopaedic Clinic Patient Information	RHC 280	English
Carpal Tunnel Release	RHC 368	English
Bladder Surgery	RHC 367	English
Knee Arthroscopy	RHC 372	English
Your Guide to Total Knee Replacement (Colour Booklet)	RHC 375	English
Hernia Repair	RHC 376	English
Laparoscopic Cholecystectomy	RHC 384	English
Release of Liability For Refusal of Blood and Blood Products	RHC 421	English
Blood Transfusion Information	RHC 603	English
Total Knee Arthroplasty – Patient Plan of Care	RHC 756	English
Pre-Admission Passport	RHC 887	English
Gastroscopy (ACU)	RHC 1081	English
Colorectal Screening Program – Colonosocpy	RHC 1136	English
Influenza Letter – Infection Control	RHC 1194	English & French
How to prepare for your gynecology procedure	RHC 1282	English
Tonsillectomy, Adenoidectomy, or Adenotonsillectomy Surgery	RHC 1487	English
How to prepare for your surgery	RHC 2022	English
Pre-Op Hip Class	RHC 2109	English & French
Pre-Op Knee Class	RHC 2110	English & French
Shoulder Surgery Discharge Instructions	RHC 2161	English
Patient and Family Experience Survey	RHC 2286	English & French
Hysterectomy Surgery Post-Operative Discharge Instructions	RHC 2599	English
Hysterectomy Surgery	RHC 2600	English
Self-monitoring in preparation for surgery/procedure	RHC 2983	English
COVID 19 Screening for Elective Surgery	RHC 3090	English
3M™ SoluPrep™Antiseptic Skin Cleanser Sponge	No RHC #	English

Name	Number	Language
Patient Instructions for Pre-Admission Clinic	RHC 259	English
Preparing for Surgery – Anesthesia Explained	RHC 778	English
Venous Thromboembolism	RHC 807	English
Information About Your Hospital Stay and Discharge	RHC 1682	English

Name	Number	Language
Patient Instructions for Pre-Admission Clinic	RHC 259	English
Preparing for Surgery – Anesthesia and Pain Control Explained	RHC 778	English
Venous Thromboembolism	RHC 807	English
Information About Your Hospital Stay and Discharge	RHC 1682	English

Name	Number	Language
Pre-Operative Questionnaire	RHC 2026	English
Pre-Procedure Questionnaire	RHC 2568	English & French

Name	Number	Language
Colorectal Cancer Screening Clinic Referral Form	RHC 427	English
Referral to Patient Blood Management Program at North Bay Regional Health Centre	RHC 3083	English
North East Hip and Knee Replacement Referral Form (PDF) \| Fillable Word Form	No RHC #	English

Name	Number	Language
Surgical Information for Surgeon/Anesthesiologist/Surgical Assistants	RHC 871	English
Surgical Booking Checklist	RHC 2021	English
Ophthalmology Clinic Physician Appointment (Dr. Vijay)	RHC 2835	English
Pacemaker Generator Change Pre Op	PPO-1-001	English
Permanent Pacemaker Initial Implantation Pre-op	PPO-1-007	English
Cataract Surgery	PPO-6-061	English
Post-Operative Laparoscopic Total Hysterectomy	PPO-6-072	English
Preoperative Patient Orders	PPO-6-080	English

50 College Drive,
P.O. Box 2500
North Bay, ON
P1B 5A4
Tel: 705-474-8600

680 Kirkwood Drive,
Sudbury, ON
P3E 1X3
Tel: 705-675-9193
Fax: 705-675-6817

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