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Pathology

Robert R. Cawley, D.O.

Dover, NH 03802

Education & Training

Board Certification

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WDH Forms Library

WDH Forms LibraryDo you need a form that is not on this page? E-mail your request to HelpDesk@wdhospital.org. Include the form number or as much information as you know about it. 

Request Forms

Cardiology, Echo, & Vascular Imaging (7031-64MR.pdf)
Code Change (8221-06MR.pdf)
Computerized Tomography (CT) Scan (7040-119MR.pdf)
Laboratory Services (7010-03MR.pdf)
Magnetic Resonance Imaging (MRI) (7040-112MR.pdf)
Nuclear Medicine Examinations (7040-120MR.pdf)
Outpatient Neurology and Sleep Disorder Testing (7120-03MR.pdf)
P.E.T./CT Scheduling (7040-121MR.pdf)
Procedure (6233-18MR.pdf)
Procedure/Surgery (8410-05MR.pdf)
Radiology Diagnostic Imaging (7040-03MR.pdf)
Ultrasound Imaging (7040-117MR.pdf)
 

Regular Forms

Anesthesia Questionnaire (7080-02MR.pdf)
Asthma Discharge Plan (6231-204MR.pdf)
Bedside Procedure Sheet (7182-02.pdf)
Cardiac Rehab Services Physician Referral (7091-04MR.pdf)
Charge Capture Folder (7182-01.pdf)
Consent for Invasive Cardiovascular Procedures (7031-71MR.pdf)
Consent for Transfusion of Blood / Blood Products (8410-25MR.pdf)
Contrast (Iodinated) Questionnaire (7040-124MR.pdf)
CT Colonography History Form (7040-126MR.pdf)
- CT Colonography Prep Instructions (7040-136.pdf)
CT History Form (7040-127MR.pdf)
CT Ordering Cheat Sheet (7040-141.pdf)
Diabetes Services - Blood Sugar Log (7130-08MR.pdf)
Diabetes Services Referral Form (7130-11MR.pdf)
Guideline for Obstructive Sleep Apnea (OSA) Evaluation (6171-30MR.pdf)
History and Physical Form (6217-33MR.pdf)
Infusion Info Data Sheet For Medicare Patients (6011-282MR.pdf)
MRI Patient Safety Questionnaire (7040-53MR.pdf)
MRI Ordering Cheat Sheet (7040-142.pdf)
Nuclear Medicine Cheat Sheet (7040-143.pdf)
- Oncology Therapeutic Massage Intake and Consent (6221-09MR)
- Oncology Therapeutic Massage Therapy Permission Form (6221-11MR)
Outpatient Consent For Seasonal Influenza Vaccine Inactivated Influenza Vaccine Injection (8420-17MR.pdf)
Outpatient Diet Consultation Referral Form (8050-01MR.pdf)
- Outpatient Pulmonary Rehab – Patient Referral Form (6171-12MR.pdf)
- Pediatric Client Intake Form (6221-10MR)
PET Prep Instructions (7040-144.pdf)
Authorization For Release Of Health Information (8402-03MR.pdf)
Positive Airway Pressure Script (7120-22MR.pdf)
Post-Procedure Notes (6011-61MR.pdf)
Pre-Operative History (6233-06MR.pdf)
Pre-Registration Form for Womens and Childrens' (8241-45MR.pdf)
Progress Notes (7181-16MR.pdf)
Radiology Ordering Cheat Sheet (7040-146.pdf)
Refusal of Medical Treatment (6011-28MR.pdf)
Rehabilitation Services Referral (7091-72MR.pdf)
Sleep Disorder Center CPAP Workshop (7120-21MR.pdf)
Surgical Services Booking Form (6217-38.pdf)
Ultrasound Indications Cheat Sheet (7040-140.pdf)
Underwater Birth Informed Consent & Risk Discussion (6080-98MR.pdf)
- WHI - Intake / New Referrals (6238-03MR.pdf)
 

Physician Order Forms

- Actemra (Tocilizumab) Infusion (6011-193MR.pdf)
Anticoagulation New Start Orders (ITC) (6011-204MR.pdf)
Belimumab (Benlysta) (6011-267MR.pdf)
Blank (7181-04MR.pdf)
Boniva (6011-148MR.pdf)
Coastal Neurology Video EEG Order (7120-06MR.pdf)
Fingolimod (Gilenya) First Dose Monitoring (6011-275MR.pdf)
Fluid/Tissue Specimen Order (7010-15MR.pdf)
Golimumab (Simponi-Aria) (6011-284MR.pdf)
Gynecologic Services – Same Day Surgery – AM Admit (6225-09MR.pdf)
Gynecologic Services Surgery Orders (6217-12MR.pdf)
Methotrexate for Ectopic Pregnancy (6231-240MR.pdf)
Natalizumab (Tysabri) Infusion Orders (6011-300MR.pdf)
- Ocrelizumab (Ocrevus) Infusion Therapy Order (6011-305MR)
Orencia (6011-146MR.pdf)
Otolaryngology Service – Inpatient (6217-44MR.pdf)
Otolaryngology Service – Same Day Surgery (6217-25MR.pdf)
Outpatient Blood Transfusion/Consent Packet
Outpatient General Labor & Delivery (6080-216MR.pdf)
Outpatient IVIG Infusion (6011-299MR.pdf)
Outpatient Vedolizumab (Entyvio) Infusion Order (6011-294MR.pdf)
- Outpatient Zoledronic Acid (Reclast) Infusion Orders (6011-147MR.pdf)
Pulmonary Function Testing (6171-23MR.pdf)
Remicade (6011-145MR.pdf)
Rituxan (Rituximab) Infusion Therapy Center (6011-277MR.pdf)
Secretin Stimulation Test for Diagnosis of Gastrinoma (6233-37MR.pdf)
Telemetry (6024-05MR.pdf)
Total Joint/Orthopedic Same Day Surgery/AM Admit (6225-02MR.pdf)
Xolair Physician Order Form (7149-01MR.pdf)

Pre-Op Orders
Cataract Surgery (6225-05MR.pdf)
Cesarean Section (6080-309MR.pdf)
Gateway Urology (6225-07MR.pdf)
General Surgery (6225-08MR.pdf)
Generic (6225-03MR.pdf)
GYN (6225-09MR.pdf)
Ortho SDS/AM Admit (6225-02MR.pdf)
Thoracic Surgery (6225-104MR.pdf)
Vascular (6225-04MR.pdf)

Post-Op Orders
Cesarean Section (6080-97MR.pdf)
 

Cath Lab

Electrophysiology Pre-Procedure Orders (7031-110MR)
Permanent Pacemaker/Generator
Pre-Cath Orders
Request for Cardiovascular Services (7031-64MR)
Request for Electrophysiology Services (7031-108MR)
TEE-CV Order Packet
Vascular Orders