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 - Northwestern Memorial Hospital - Chicago

Preoperative Information for Physician Offices

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

Important Forms

NOTE: Please complete the Health History Form for ALL patients who will be having surgery or a procedure at NMH. You should also complete the Clinic Order Form for all patients who will have their preoperative evaluation done at the NMH Preoperative Clinic.

Please have your patient complete the NMH Preoperative Clinic Health History Form (pdf) and fax it to the efax server at 312-926-9081.

If your patient will be having his/her preoperative evaluation done at the NMH Preoperative Clinic, please complete the NMH Preoperative Clinic Order Form (pdf) and fax it to the efax server at 312-926-9081. Give the patient a copy of this completed form so that he or she may schedule their appointment.

For your reference, you may use the NMH Preoperative Clinic Triage Form (pdf) 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

The NMH Preoperative Clinic Lab Testing Matrix (pdf) is the algorithm used by the NMH Preoperative Clinic to order tests and studies for your patient. The clinic will follow this algorithm when you select the option of “Disease-Based testing” on the Order Form.

The Minimum Surgical Blood Order Schedule (pdf) is the NMH 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.

Should you wish, you can provide your patient with the Patient Instructions for Surgery (pdf) which provides detailed information for patients on how to prepare for their surgery or procedure at NMH.

Additional Protocols

Screening for MSSA,MRSA is performed at the NMH Preoperative Clinic for patients undergoing total joint replacements and spine fusions. The screening and treatment protocols, as well as educational materials for patients, are available below.


Last UpdateMay 25, 2012