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These forms require Adobe Acrobat Reader, which is free. If you don't
already have the Acrobat Reader, it can be found here.
Pre-Admission/Registration
Form
You and your physician can use this form to provide Hilo Medical Center
with the information we will need to prepare for your visit.
Completing this form fully will help streamline the process of your admission
or registration. Fax it to (808) 974-6869 and bring a copy with you on
the day of your procedure.
Health Connect
Hilo Medical Center Remote Access Portal
- for physicians and business partners
Forms for the physician and physician's office.
Diagnostic Imaging Requisition
Surgery Requisition
Physician Orders
These forms are provided for reference only. Please use the Standard Register forms for inclusion in the medical record.
322-0002 ANESTHESIA RECORD rev 11-08
322-0007 CODE STATUS rev 08-07
2012-322-0009 CONSENT FOR PROCEDURE rev 08-12
2012-322-0009 CONSENT FOR PROCEDURE rev 08-12 (Fillable)
322-0009A ULTRASOUND GUIDED PARACENTESIS CONSENT FORM rev 12-08
322-0073 NURSERY ADMISSION RECORD rev 11-09
322-0086 PATIENT TRANSFER FORM rev 10-09
322-0107 RECORD OF DEATH FORM rev 05-09
322-0181 ADMINISTRATION OF CHEMO DRUGS CONSENT FORM rev 04-09
322-0263 RESTRAINT SECFUSION ORDER FORM rev 04-09
322-0267 CODE BLUE rev 06-10
322-0296 INHOUSE TRANSFERS rev 10-08
322-0305 DRS HIRATA AND EBESUGAWA ORDERS rev 07-07
322-0342 TRANSFERS BETWEEN UNITS rev 08-08
322-0363 POST OP NOTE REQ OPTIONAL 10 17 11
322-0379 PROCEDURAL SEDATION rev 04-10
322-0413 EPIDURAL INTRATHECAL ORDERS rev 02-10
322-0414 HEPARIN INFUSION ORDER FORM rev 10-09
322-0440 POST ANESTHESIA ORDERS rev 02-10
322-0490 CLARIFICATION OF REHAB ORDERS rev 12-09
322-0510 INTERDISCIPLINARY EDUCATION DOCUMENTATION TOOL rev 04-09
322-0521 LABOR EPIDURAL INTRATHECAL ORDERS rev 11-09
322-0536 CHEMO EDUCATION TOOL rev 11-09
322-0543 EMERGENCY DEPARTMENT RECORD FORM rev 05-07
322-0561 HYSTERECTOMY MD ORDERS rev 05-09
322-0581 DRS PIERCE PATTERSON POST OP ORDERS rev 02-09
322-0582 INSULIN SLIDING SCALE rev 02-08
322-0591 PREOP ORDERS FOR DRS PIERCE & PATTERSON rev 02-09
322-0592 APPOINT NON-DESIGNATED SURRAGOTE FORM rev 08-10
322-0599 RESPIRATORY THERAPY ORDERS rev 03-06
322-0604 HALE HO'OLA PREPRINTED ADMIT ORDERS rev 01-10
322-0607 CERTIFICATE OF TRANSFER rev 06-05
322-0631 ALCOHOL DETOX PROTOCOL rev 03-06
322-0646 EEG ORDER FORM rev 01-12
322-0659 ER THROMBOLYTIC ISCHEMIC STROKE ORDERS rev 04-10
322-0667 NIS SCALE rev 07-08
322-0669 MRI PATIENT SCREENING FORM rev 05-06
322-0687 DEEP VENOUS THROMBOSIS ver 04-06
322-0695 RADIOLOGY PRELIMINARY REPORT rev 12-09
322-0706 COMFORT CARE ORDERS rev 12-08
322-0728 RAPID RESPONSE RECORD rev 03-09
322-0732 TELEMETRY ORDERS rev 09-07
322-0737 SNF-ICF LEVEL OF CARE ORDERS rev 12-08
322-0751 SURROGATE FORM rev 05-07
322-0752 WITHDRAWAL OF NUTRITION CONSENT rev 05-07
322-0753 NITTA BLANK CONSENT FORM rev 05-07
322-0754 NITTA PITOCIN rev 05-07
322-0764 MEDICARE RIGHTS FORM rev 10-09.pdf
322-0770 VAD ASSESSMENT rev 08-07
322-0773 RT-PHARMACIST DRUG ORDER CHANGE rev 04-08
322-0776 RT PHARMACY MED FORM rev 08-07
322-0778 ORAL WARFARIN ORDERS rev 04-08
322-0782 ICU ADMIT ORDERS rev 12-09
322-0791 DR SANTIAGO'S POST OP ORDERS rev 12-07
322-0792 CONTACTING JOINT COMMISSION
322-0806 DR SANTIAGO PATIENT INTAKE FORM rev 04-08
322-0807 IMAGING ORDER FORM rev 01-07
322-0809 OB H&P FORM rev 02-08
322-0811 DRS PIERCE AND PATTERSON SURGERY ADMISSIONS rev 03-08
322-0830 NEWBORN ADMIT FORM rev 07-10
322-0841 CARDIAC ADMIT ORDERS rev 01-10
322-0919 PRE CATH ORDERS rev 06-08
322-0920 POST ANGIO ORDERS rev 06-08
322-0921 POST CORONARY INTERVENTION ORDERS rev 06-08
322-0922 NEWBORN ANTIBIOTIC ORDERS rev 06-08
322-0923 PERSANTINE CARDIAC NUCLEAR SCAN DR SAMMOND rev 06-08
322-0924 LTC UTI PROTOCOL FAX rev 05-09
322-0929 VTE ABX rev 08-10
322-0930 INITIAL INFANT STABILIZATION FORM rev 10-08
322-0931 CIRCUMCISION PROCEDURE NOTE rev 10-08
322-0932 NURSERY IDT PROGRESS NOTE rev 08-08
322-0933 NEONATAL ABSTINENCE FORM rev 08-08
322-0935 MAG SULFATE PRETERM LABOR rev 10-08
322-0936 MAG SULFATE FOR PIH rev 10-08
322-0937 REQUEST FOR PLACENTA FORM rev 08-08
322-0940 PICC ORDER FORM rev 11-09
322-0943 ASTHMA ACTION PLAN rev 10-08
322-0947 CARDIAC CATH POST PROCEDURE rev 10-08
322-0952 CT PROTOCOL rev 10-08
322-0953 BIOPSY PROTOCOL rev 10-08
322-0954 Hospitalist Progress Report
322-0967 PERMACATH ORDERS rev 12-08
322-0971 SUBCUTANEOUS INSULIN ORDERS rev 03-10
322-9000 MATSUURA INTERDISCIPLINARY PROGRESS REPORT rev 08-09
322-9001 MATSUURA CONSENT FORM rev 10-09
322-9002 MATSUURA POST-OP ORDERS rev 12-09
322-9003 MATSUURA PRE-OP ORDERS rev 12-09
322-9004 MATSUURA POST-OP HIP FRACTURE rev 08-09
322-9005 MATSUURA DISCHARGE ORDERS rev 08-09
322-1015 SBAR COMMUNICATION FORM rev 11-09
322-1017 SSU EYE CASES rev 10-09
322-1018 POST ANGIO CATH ORDERS rev 10-09
322-1020 CENTRAL LINE CHECKLIST rev 02-10
322-1021 LAB TELE STRIP NEW FORM rev 10-09
322-1023 INFLIXIMAB ADMINISTRATION ORDERS rev 04-10
322-1026 GENERAL ADMIT ORDERS rev 02-10
322-1028 LTC MD FAX ORDER FORM rev 03-10
322-1029 TRAUMA FORM rev 01-10
322-1030 OT BH ASSESSMENT rev 02-10
322-1039 DR HELMS PRE-OP ORDERS rev 06-10
322-1040 DR HELMS CS AND-OR MAJOR SURGERY ORDERS rev 04-10
322-1041 DR HELMS MINOR SURGERY POST-OP ORDERS rev 04-10
322-1072 PERIOPERATIVE BETA-BLOCKER THERAPY AND VTE PROPHYLAXIS ORDERS rev 04-10
322-1073 DENTIST CHART NOTES rev 05-10
322-1075 PRONOUNCEMENT OF DEATH BY PHONE rev 08-10
322-1077 HIV NOTIFICATION FORM rev 08-10
322-1078 CHECKLIST FOR HIV TESTING WITHOUT PRIOR PATIENT CONSENT 08-10
322-1079 CONSENT TO RELEASE INFO TO PUBLIC rev 08-10
322-1081 CONSENT TO PHOTOGRAPH (ADULTS) rev 08-10
322-1082 WITHDRAWAL OF ARTIFICIAL NUTRITION HYDRATION WITHDRAWAL FORM rev 08-10
322-1084 LACK OF CAPACITY DETERMINATION FOR SURROGATE DECISION MAKING rev 08-10
322-1086 NURSING HOME DECISION SIGNATURE FORM rev 09-10
322-1087 VACCINE FREEZER LOG rev 09-10
322-1098 Same Day Surgery PT Form 2.23.11
REMICADE MEDICATION GUIDE rev 11-09
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