Neurosurgery Discharge Form
Please complete this form to ensure a safe and informed discharge following your neurosurgery procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (for follow-up communication)
example@example.com
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Neurosurgery Performed
*
Please Select
Tumor Removal
Aneurysm Clipping
Spinal Surgery
Trauma Surgery
Other
Date and Time of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Discharge Instructions (Wound Care, Activity Restrictions, etc.)
*
Medications Prescribed at Discharge
*
Follow-up Appointment Details (Date, Time, Location, Physician)
*
Please select any warning signs you were instructed to watch for after discharge:
*
Severe headache
Fever or chills
Worsening weakness or numbness
Seizures
Drainage or redness at incision site
Confusion or difficulty waking up
Other
Emergency Contact Name and Phone Number
*
Patient or Caregiver Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: