Infection Control Discharge Form
Please complete this form upon discharge to ensure proper infection control procedures are followed.
Patient Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Infection Type
Please Select
Bacterial
Viral
Fungal
Parasitic
Other
Treatment Given
Precautions to be Taken
Follow-up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharging Nurse/Doctor Name
First Name
Last Name
Signature of Discharging Nurse/Doctor
Submit
Should be Empty: