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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) |

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| | |

| |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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MRUN: 752-30-57

DOB: AGE: SEX:

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