Fertility Clinic Discharge Form
Please complete this form to document your discharge from the fertility clinic and acknowledge receipt of post-care instructions.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Treatment Summary
*
Were there any complications during your treatment?
*
No complications
Minor complications (resolved)
Major complications (please specify below)
If you selected 'Major complications', please provide details below:
Discharge Instructions Provided
*
Medication instructions reviewed
Activity restrictions explained
Follow-up appointment scheduled
Emergency contact information provided
Other
Follow-up Appointment Date (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: