Burn Treatment Discharge Form
Please complete this form to ensure all necessary information is provided for a safe discharge following burn treatment.
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.
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Burn Location(s) on Body
*
Burn Severity
*
Please Select
First-degree (Superficial)
Second-degree (Partial Thickness)
Third-degree (Full Thickness)
Other
Brief Description of Burn Cause (e.g., scald, flame, chemical)
*
Summary of Treatment Provided
*
Wound Care Instructions for Home
*
Medications Prescribed (name, dosage, frequency)
*
Signs and Symptoms Requiring Immediate Medical Attention (check all that apply)
*
Fever or chills
Increased pain or redness
Swelling or pus
Bleeding from wound
Foul odor
Other
Next Follow-up Appointment Date (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name and Phone Number
*
Submit Discharge Form
Should be Empty: