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|COUNTY OF COUNTY NAME HERE DEPARTMENT OF |
|HEALTH SERVICES |
|COUNTY NAME HERE + MEDICAL CENTER NAME HERE |
|Today’s date: |PCP: |
|PATIENT INFORMATION |
|Last Name: |First: |Middle: |Birth |Age: |
| | | |Date: | |
| | | | | |
|Street address: |Social Security no.: |Home phone no.: |
| | | |
|P.O. Box: |City: |State: |ZIP Code: |
| | | | |
|Occupation: |Employer: |Employer phone no.: |
| | | |
|Admittance Date: |Discharge Date: |Return to School/Work: |
| | | |
| |
| | |
|Your Doctor’s Diagnosis is: |Diabetic: 1050 Fast-Track |
| | |
| |If you have a morning appointment, do not eat or drink before your doctor/nurse sees |
| |you. Bring a snack and your diabetic medication with you. |
| | |
|Today you received: |Prescription: |
| | |
|Medical Evaluation and Examination |You received a prescription today. Please go to our pharmacy and begin taking your |
|CHC Map and Phone Numbers |medication as directed. |
|Prescription | |
|Instruction Sheet: |Follow label instructions carefully. |
|Cast Care □ Wound Care |Bring ALL medications to any future appointment. |
|Head Injury | |
|Sprains/Strains | |
|Other: __________________________________ | |
| | |
|Important Instructions: |Other Instructions: |
| | |
|If at any time you begin to feel worse, experience new symptoms, or you |Return to ER if symptoms return or for any other concerns. |
|are not improving as expected, you are advised to return to the emergency | |
|department immediately. | |
|If you are seriously ill, please call 911. | |
|If you continue to improve, you can wait for your next scheduled doctor’s | |
|appointment. | |
DEPARTMENT OF EMERGENCY MEDICINE
DISCHARGE INSRUCTIONS
T-1082 FILE IN MEDICAL RECORD PAGE 1 OF 2 1082 (6-07)
| | |
| | |
|Your Doctor has suggested that you receive medical follow up: |I hereby acknowledge receipt of the written instructions that are checked |
| |above. I acknowledge that I have received emergency care and understand the |
|Keep your scheduled follow-up appointment(s): |need for close follow up as instructed. |
|Please call the phone number given you today o make a follow up appointment in | |
|the next week. | |
|You will be getting an appointment in the make. If you have not received the | |
|appointment in 4-6 weeks, please call (555) 555-5555. |(signature of patient or responsible person) |
|Call your private doctor or any local clinic for an appointment so you can be | |
|rechecked in the next several days. | |
|Your doctor wants you to return to room 1050/100 for a repeat exam on your | |
|scheduled day. You must register 30 minutes before your appointment time in room |(if not signed by patient, state relationship to patient) |
|555. | |
| | |
| | |
| |(Witness) |
| | |
| | |
| | |
| |(Date) |
| | |
| | |
| | |
| | |
| |Emergency Department Phone Numbers: |
| | |
| |1050: (555) 555-5555 1060: (555) 555-5555 |
| | |
| |1350: (555) 555-5555 |
DEPARTMENT OF EMERGENCY MEDICINE
DISCHARGE INSRUCTIONS
T-1082 FILE IN MEDICAL RECORD PAGE 2 OF 2 1082 (6-07)
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