Patient Medical Discharge Check-Out Form
Complete all sections to finalize the patient discharge process. Please review and acknowledge all instructions before submitting this Patient Medical Discharge Check-Out Form.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Attending Provider Name
*
Discharge Diagnosis or Summary
*
Medications Prescribed at Discharge
*
Follow-Up Instructions
*
Have all personal belongings been returned to the patient?
*
Yes
No
Emergency Contact Name and Phone Number
*
Patient Acknowledgement
*
I confirm that I have received and reviewed my discharge instructions and had the opportunity to ask questions.
Patient Signature (acknowledges that discharge instructions were reviewed)
*
Submit Check-Out
Submit Check-Out
Should be Empty: