Orthotics Discharge Form
Document the discharge process for patients receiving orthotic devices, including device details, instructions, and patient acknowledgment.
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.
Orthotic Device Type
*
Please Select
Foot Orthosis
Ankle-Foot Orthosis (AFO)
Knee-Ankle-Foot Orthosis (KAFO)
Upper Limb Orthosis
Spinal Orthosis
Other
Side of Device
*
Left
Right
Bilateral
Date of Fitting
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Discharge
*
Please Select
Treatment Completed
Device No Longer Needed
Device Replaced/Upgraded
Non-compliance
Other
Discharge Instructions Provided to Patient
*
Care and Maintenance of Device
Signs of Skin Breakdown
Proper Use Instructions
Follow-up Appointment Scheduled
Contact Information Provided for Questions
Other
Additional Discharge Notes
Recommended Follow-up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Patient or Guardian
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: