This physician's order sheet requires an interview with an anesthesiologist or pre-admission nurse, even if testing is done elsewhere. It also requires the patient to provide any previous testing or physical examination forms and information on allergies. A blood bank specimen must be obtained within 7 days of surgery, except in certain cases where it is required within 3 days, such as for pregnant patients, those who had a miscarriage, patients recently transfused, or current inpatients. Consent is also needed for the blood bank specimen.

2. PHYSIClAN'S ORDER SHEET/PRE-ADMISSXON TESTING ORDERS An interview with the Anesthesiologist and/or
Pre-Admission R.N. is necessary even iflesting is done elsewhere. Please bring any testing re: and/or physical examination
fonns.
Allergies (Food/Drug/Latex): ( )NKA
BLOOD BANK: Blood Bank specimen must be obtained within 7 days of surgery. (Exceptions must be within three days:
pregnant or miscarriage, patient transfused within past three months, all inpatients. Consent also required.)