Oral Thrush Discharge Instructions Form
Please review and acknowledge your oral thrush discharge instructions below.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medication Instructions
*
Oral Care Instructions
*
Diet Recommendations
Warning Signs to Watch For
*
Follow-Up Appointment Needed?
*
Yes
No
Preferred Contact Method for Questions
Please Select
Phone
Email
Other
Contact Details (phone or email)
I acknowledge that I have received and understand these discharge instructions.
*
Yes, I acknowledge
Submit
Should be Empty: