Patient/Physician Forms

Printable Forms

These forms can be instantly downloaded and printed for your convenience.

General Forms

• Consent for Administration of Blood or Blood Products Used for Patients Without Surgical Consent Form 
• WakeMed History & Physical (H&P) Form
• WakeMed OneCall Scheduling Fax Form
• CMS Addendum E Inpatient Only List

Anesthesia Forms

• Anesthesia Preoperative Patient Information  English  |  Spanish
• Regional Anesthesia (Nerve blocks)  English  |  Spanish    
• AICD and or Pacemaker Preop Eval Form (N-375)
• Request for Preoperative Cardiac Evaluation
• Guidelines for Preanesthesia Assessment

Heart & Vascular

• Home Medications and Other Health Information Sheet
• Request for Preoperative Cardiac Evaluation
• AICD and or Pacemaker Preop Eval Form (N-375)

Labor & Delivery

• Anesthesia for Labor and C-Section  English  |  Spanish
• Women's Pavilion & Birthplace Pre-Registration Form  English  |  Spanish

Consent for Surgery and Special Procedures

• Informed Consent Form N-712  English  |  Spanish
• Informed Consent Form N-712A  English  |  Spanish

Authorization to Release Medical Information Forms

• Authorization to Release Medical Information  English  |  Spanish

Note: The form can faxed to 919-350-7985 or mailed to: Medical Record Services - ROI, 3000 New Bern Avenue, Raleigh NC 27610

Imaging Services

• Imaging Services Order Form | Page 2

Rehabilitation

• Outpatient Rehab Registration Form
• WakeMed Rehab Outpatient Services Intake Profile 

Diabetes

• Pregnancy & Diabetes Program - Physician Order Form

Mail Order Forms

These forms are printed by WakeMed and can be ordered online and mailed to your practice in bulk at no charge.

Physician Office Orders

• Online order form