Follow-up Instructions

Keep this page and take it with you to your next appointment. Follow only the instructions checked below.

• Call your doctor or the Emergency Department if you develop any unusual signs or symptoms within the next 24 hours, especially:
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• No follow-up appointment is necessary unless you develop any of the symptoms listed above.
• Call for an appointment with Dr. _____________ in the practice of ___________________.
  When you call for your appointment, please say that you were treated in the Emergency Department at ____________ Hospital by _______________ and were advised to be seen again in ______ days.
• Return to the Emergency Department/Clinic on __________ (date) at ____________ AM/PM for a follow-up examination.
• Do not perform vigorous physical activities for 1 to 2 days.
• You may resume everyday activities including driving and operating machinery.
• Do not return to work for _______ days.
• You may return to work on a limited basis. See instructions below.
• Avoid exposure to cigarette smoke for 72 hours; smoke may worsen the condition of your lungs.
• Avoid drinking alcoholic beverages for at least 24 hours; alcohol may worsen injury to your stomach or have other effects.
• Avoid taking the following medications: ________________________________
• You may continue taking the following medication(s) that your doctor(s) prescribed for you:
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• Other instructions:
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• Provide the Emergency Department with the name and the number of your primary care physician so that the ED can send him or her a record of your emergency department visit.
  
  
• You or your physician can get more information on the chemical by contacting: ____________________________ or ____________________________, or by checking out the following Internet Web sites: ________________________; ___________________________.