Breast Cyst Discharge Instructions Form
Please review and acknowledge the following discharge instructions after your breast cyst-related appointment.
Patient Full Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Brief Description of Procedure (e.g., cyst aspiration, ultrasound, etc.)
*
Key Discharge Instructions
*
Keep the area clean and dry
Avoid strenuous activity for 24 hours
Monitor for signs of infection (redness, swelling, pain)
Take prescribed medications as directed
Apply ice to the area if recommended
Other
Warning Signs That Require Medical Attention
*
Fever over 100.4°F (38°C)
Increasing redness or swelling at the site
Persistent or worsening pain
Unusual discharge or bleeding
Other
Recommended Follow-Up Actions
*
Schedule follow-up appointment
Return for imaging as instructed
Monitor symptoms and report changes
Other
Contact Information for Questions (e.g., clinic phone or nurse line)
*
Do you understand the above discharge instructions?
*
Yes
No
Additional Comments or Questions
Acknowledgment of Receipt of Discharge Instructions
*
I have received and reviewed the discharge instructions above.
Submit
Should be Empty: