MERIDIANHEALTH | sUMG JANE H: BOOK! HEALTH CENTER 1501122978 ogia4j15 CENTER FOR PEDIATRICS, Poc PATIENT INFORMATION & DISCHARGE INSTRUCTIONS CURRY MILO CAMERON. ‘°° 60217-503NX (5-11) Page 1 of 1 0868418 08/31/15 OM E007842436 I AAtn Dr: PINTO, JAMIE M AIOE “Dce701" PATIENT INFORMATION AND DISCHARGE INSTRUCTIONS Date: Yu ys Age: _(/dtyS Weight: __ Height: PURPOSE OF TODAY'S VISIT: —— WELL CHILD GARE VISIT: SICK VISIT: FOLLOW UP OR RECH —_—— [OTHER: — — MEDICATIONS PRESCRIBED FOR THIS PATIENT OR CHANGES IN MEDICATIONS: Head Circumference: NAME OF MEDICATION DOSE | HOW OFTEN | FOR HOW LONG [SPECIAL INSTRUCTIONS 1 @ oy, —_____| | —__| — 3. 4 _ | __ 5. | REFERRALS: __REFERRALS a _ _ SPECIALIST or SERVICE REASONFOR | PHONENUMBER [SPECIAL INSTRUCTIONS REFERRAL Additional Instruction: 1 2 3 — 4 5 6. Patient Advisor/Anticipatory Guidance Handout Given for English Spanish 3 ; — __“Thesoxg_ 123°. Return to Family Health Center in 4 ysiwocks/months for a: Follow Up°P Well-Child Visit With Your Resident Doctor or Nurse Practitioner: — — _ Or sooner if symptoms of illness, symptoms worsen, no improvement or new concerns develop. Call 732-776-4660 with any questions during the day Monday-Friday. Call the Answering Service after 4:00 p.m. and weekends at 732 974-5870 Attending Doctor, Resident or Nurse Practitioner seen today Linh Engr Signature: __ J Dates _49/n/15 time: 10:5