Men’s Health Discharge Form
Please complete this form to document patient discharge and ensure safe follow-up care.
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
example@example.com
Discharge Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Primary Reason for Visit / Diagnosis
*
Discharge Instructions (please review carefully)
*
Were any medications prescribed at discharge?
*
Yes
No
List all prescribed medications (if applicable)
Follow-up Appointment Scheduled?
*
Yes
No
Follow-up Appointment Date and Time (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Symptoms to Watch For After Discharge (select all that apply)
*
Fever
Pain or swelling
Difficulty urinating
Bleeding
Shortness of breath
Other (please specify)
Emergency Contact Name and Phone Number
*
Patient Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: