Medical Patient Sign-Out Form
Please complete all sections below to document the patient sign-out process accurately.
Patient Full Name
*
First Name
Last Name
Date of Sign-Out
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Sign-Out
*
Hour Minutes
AM
PM
AM/PM Option
Person Responsible for Sign-Out
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Parent/Guardian
Spouse/Partner
Other Family Member
Friend
Other
Destination / Discharge Location
*
Method of Transportation
*
Please Select
Private Vehicle
Taxi/Rideshare
Public Transportation
Ambulance
On Foot
Other
Personal Belongings Returned
*
Yes
No
Not Applicable
Staff Witness Name
*
First Name
Last Name
Additional Comments or Notes
Signature of Person Responsible for Sign-Out
*
Submit Sign-Out
Submit Sign-Out
Should be Empty: