Birthmark Discharge Instructions
Please review and complete this form to ensure you understand your post-procedure care and follow-up instructions.
Patient Full Name
*
First Name
Last Name
Patient 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 Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Birthmark Treated
*
Type of Procedure Performed
*
Please Select
Laser removal
Surgical excision
Cryotherapy
Other
Post-Procedure Care Instructions
*
Warning Signs to Watch For (check all that apply)
*
Excessive redness or swelling
Bleeding that does not stop
Fever over 100.4°F (38°C)
Pus or unusual discharge
Severe pain not relieved by medication
Other
Recommended Follow-Up Appointment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Information
*
Additional Notes or Questions
Signature of Patient or Legal Guardian
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: