Toe Amputation Discharge Instructions

Toe Amputation Discharge Instructions
Please review and acknowledge your discharge instructions for optimal recovery after toe amputation.
Patient Full Name*
First NameLast Name
Date of Birth*
MonthDayYear
Date
Date of Surgery*
MonthDayYear
Date
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Wound Care Instructions*
Medications and Dosage Instructions*
Activity and Mobility Restrictions*
Increased redness or swelling around the woundFever over 101°F (38.3°C)Persistent or increasing painFoul-smelling or unusual drainageBleeding that does not stopOther
Follow-Up Appointment Date and Time*
MonthDayYear
Date
Hour MinutesAM/PM Option
Emergency Contact Name and Phone Number*
Patient or Caregiver Signature*
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