New York Eye and Ear Infirmary
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New 72 Hour Policy

Instructions

You may complete these forms in 2 different ways:

  1. Fill out the form online, using your keyboard and mouse and then print & fax it to 1-866-333-0174.
  2. Print the form and complete the requested information using a black or blue pen and then print & fax it to 1-866-333-0174.

All forms should be submitted to the Admitting Office at least 72 hours in advance of surgery. 

Although one can simply print out any given form as is and then fill it out by hand, we encourage users to fill out the form using their computer so the form will be easier to read when processed. For help with filling out forms online, view our tutorial.

Looking for Patient Forms?

Forms

For Physicians: Ambulatory Surgery Pre-Operative Medical EvaluationFor Physicians: Admitting Note & Pre-Surgical OrdersAdmitting Note & Pre-Surgical Orders
(2 pages) (PDF - 537 KB)

INSTRUCTIONS:

  1. Please fill in all pertinent data.

  2. Please include the CPT / ICD 9 code associated with this diagnosis. 

  3. Please be sure to include the patient’s name.

For Physicians: Ambulatory Surgery Pre-Operative Medical EvaluationFor Physicians: Ambulatory Surgery Pre-Operative Medical EvaluationAmbulatory Surgery Pre-Operative Medical Evaluation (2 pages)
(PDF - 1.23 MB)

Cardiac Rhthym Management Devices Pre-Operative Evaulation and Information FormCardiac Rhthym Management Devices Pre-Operative Evaulation and Information Form
(PDF - 111 KB)

Consultation RequestConsultation Request and Report
(PDF - 69 KB)

For Physicians: Guidelines for Pre-Surgical Testing and Standard Pre-Operative OrdersGuidelines for Pre-Surgical Testing and Standard Pre-Operative Orders
(PDF - 96 KB)

NPO GuidelinesNPO Guidelines
(PDF - 7.6 KB)

 

Outpatient Laser Center FormOutpatient Laser Center Form
(PDF - 347 KB)

For Physicians: Patient Consent Form for Operation or Special Procedure - EnglishPatient Consent Form for Operation or Special Procedure - English
(PDF - 92 KB)

INSTRUCTIONS:

  1. Please fill in all pertinent information.

  2. Please ensure consent is signed appropriately.

For Physicians: Patient Consent Form for Operation or Special Procedure - SpanishPatient Consent Form for Operation or Special Procedure - Spanish
(PDF - 719 KB)

INSTRUCTIONS:

  1. Please fill in all pertinent information.

  2. Please ensure consent is signed appropriately.

For Physicians: Patient Consent Form for Operation or Special Procedure - EnglishPatient Consent Form for Operation or Special Procedure - Russian
(PDF - 340 KB)

INSTRUCTIONS:

  1. Please fill in all pertinent information.

  2. Please ensure consent is signed appropriately.

For Physicians: Patient Consent Form for Operation or Special Procedure - EnglishPatient Consent Form for Operation or Special Procedure - Chinese
(PDF - 389 KB)

INSTRUCTIONS:

  1. Please fill in all pertinent information.

  2. Please ensure consent is signed appropriately.

For Physicians: Pediatric History and PhysicalPediatric History and Physical
(PDF - 289 KB)

For Physicians: Physician's OrdersPhysician's Orders
(PDF - 199 KB)

Preadmission Registration Form Preadmission Registration Form for Patients
(PDF - 138 KB)

INSTRUCTIONS:
Part I Patient Information

  1. Please fill in all blanks as indicated on the form.

  2. Please print clearly.

Part II Insurance Information

  1. Please attach photocopies of your insurance cards to avoid admission delays

  2. Please fill in all blanks as indicated.

  3. Please include the insurance plan’s Pre-Certification or Authorization Number.

Part III Additional Demographic Information
Please answer all questions to expedite the patient’s admission.

Preoperative Instructions for Outpatient SurgeryPreoperative Instructions for Outpatient SurgeryPreoperative Instructions for Outpatient Surgery
(PDF - 75 KB)

Pre-Operative Patient Medication GuidelinesPre-Operative Patient Medication Guidelines
(PDF - 38.5 KB)

 

Retina Center Diagnostic Test Order FormRetina Center Diagnostic Test Order Form
(PDF - 96 KB)

Self Pay Cosmetic FormSelf Pay Cosmetic Form
(PDF - 110 KB)

Surgical Time GuidelinesSurgical Time Guidelines
(PDF - 6.8 KB)

 

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Contact Information

If you have any questions about these forms, please contact:

Admitting Department
The New York Eye and Ear Infirmary
310 East 14th Street
New York, NY  10003 (in Manhattan)
Phone: (212) 979-4114 or (212) 979-4309
FAX: 1-866-333-0174

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