Patient Education

Patient Information
Patient Name*
MRN *
Enter 6 Digits MRN number
Date of Education*

DayMonthYear
Date
SurgeryLabour & DeliveryDiabeticENTOphthalmologyGeneral
Nutrition guidelines after Bariatric SurgeryNutrition Guidelines after Balloon SurgeryColonoscopyCare of your Wound after surgeryRespiratory exerciseAmbulationCircumcisionSign of infectionOther
General postnatal careBaby carePain Management during laborPostpartum perineal careBreastfeeding Education BookletOther
Foot health care instructions diabetic patientDaily diet for a diabetic patientOther
Early hearing screening for newbornsOther
Eye careEye medicationAmblyopia (Lazy Eye)Other
Patients' rights and responsibilityHand hygieneOther
I hereby confirm that a healthcare professional has provided me with education and information regarding my care as noted above.
I have read (or had read to me) and understood all the information provided.I was given the opportunity to ask questions, and my questions were answered to my satisfaction.
Legal Guardian Name and Signature or Patient Signature*

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Signature Date*

DayMonthYear
Date
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Patient Information