Student Clinic Discharge Form
Complete this form to document the discharge of a student from the clinic, including treatment details and discharge instructions.
Student Full Name
*
First Name
Last Name
Student ID Number
*
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date and Time of Clinic Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Clinic Visit
*
Diagnosis / Assessment
*
Treatment or Care Provided
*
Medications Administered or Prescribed
Discharge Condition
*
Recovered
Improved
Stable
Referred for Further Care
Other
Discharge Instructions Provided to Student/Guardian
*
Follow-up Recommendations
Attending Provider's Name
*
Attending Provider's Contact Information
Signature of Student or Guardian
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: