Cardioversion Discharge Instructions Form
Please complete this form to confirm you have received and understood your discharge instructions following cardioversion.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Cardioversion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Responsible Provider
*
Have you received instructions about your prescribed medications?
*
Yes
No
Which symptoms should prompt you to seek immediate medical attention? (Select all that apply)
*
Chest pain
Shortness of breath
Fainting
Palpitations
Other
What activity restrictions have you been advised to follow after your procedure?
*
Please Select
No restrictions
Avoid strenuous activity for 24 hours
Avoid driving for 24 hours
Other
Date of next follow-up appointment (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred contact number for follow-up
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: