Post-Surgical Discharge Instructions Acknowledgement Form

Post-Surgical Discharge Instructions Acknowledgement Form — Form Fields

This healthcare template includes 11 fields. Confirm patients have received and understood post-operative care instructions at discharge. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Surgery (text, required)
• Procedure Performed (text, required)
• Attending Surgeon (text, required)
• Discharge Date (text, required)
• Discharge Destination (dropdown selection, required) — options: Home – Self-Care, Home – With Caregiver, Skilled Nursing Facility, Rehabilitation Center
• Instructions Reviewed (checkboxes, required) — options: Wound care, Medications, Activity restrictions, Diet instructions, Follow-up appointments, Warning signs to watch for
• Follow-Up Appointment Date (text, required)
• Emergency Contact Name (text, required)
• Emergency Contact Phone (text, required)
• Do you have any unresolved questions? (multiple choice, required) — options: No, I understand my instructions, Yes – please have a nurse contact me