Surgical Services Forms

Patient Information Forms

Name

Number

Language

Orthopaedic Clinic Patient Information RHC 280 English & French
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

 

Outpatient Pre-Admission Packages

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

 

Inpatient Pre-Admission Packages

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

 

Questionnaires

Name

Number

Language

Pre-Operative Questionnaire RHC 2026 English
Pre-Procedure Questionnaire RHC 2568 English & French

 

Referral Forms

Name

Number

Language

Colorectal Cancer Screening Clinic Referral Form RHC 427 English
ONTraC Patient Blood Management Referral: How Community Nurse Practitioners Can Help Prevent Post-operative Anemia No RHC # English
ONTraC Patient Blood Management Referral: Preventing post-operative anemia – how family physicians can help No RHC # English
North East Hip and Knee Replacement Referral Form (PDF) | Fillable Word Form No RHC # English

 

Other Forms

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

North Bay

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

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Sudbury

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

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Visitors Guide

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