Elder Rehabilitation Discharge Form
Please complete this form to ensure a safe and coordinated discharge from rehabilitation care.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Summary of Rehabilitation Progress
*
Current Medications (List all prescribed medications at discharge)
*
Follow-up Appointment Date and Time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Home Care Instructions (including dietary, mobility, and therapy recommendations)
*
Medical Equipment or Supplies Provided at Discharge (e.g., walker, wheelchair, oxygen)
Walker
Wheelchair
Oxygen
Medication Organizer
Other
Emergency Contact Name and Phone Number
*
Responsible Discharge Staff Name and Title
*
Signature of Patient or Legal Representative
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: