Dental Office Discharge Form
Please complete this form to confirm your discharge and acknowledge post-treatment instructions from your dental visit.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Treating Dentist
*
Treatment or Procedure Performed
*
Please Select
Cleaning
Filling
Extraction
Root Canal
Crown/Bridge
Implant
Other
Please list any allergies (medications, latex, etc.)
Medications Prescribed (if any)
Post-Treatment Instructions Provided to Patient
*
Oral hygiene instructions reviewed
Dietary restrictions explained
Pain management instructions given
Signs of complications discussed
Follow-up appointment scheduled or recommended
Other
Does the patient require a follow-up appointment?
*
Yes
No
Emergency Contact Name and Phone Number
Signature of Patient or Guardian
*
Submit Discharge
Submit Discharge
Should be Empty: