School Health Center Discharge Form
Please complete this form to document the student's discharge from the school health center.
Student Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade/Class
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Date and Time of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Visit
*
Please Select
Illness
Injury
Routine Check
Medication Administration
Other
Assessment/Diagnosis
*
Care or Treatment Provided
*
Discharge Status
*
Returned to Class
Sent Home
Referred to Healthcare Provider
Other
Discharge Instructions / Recommendations for Follow-up
*
Additional Notes (optional)
Submit Discharge Form
Should be Empty: