Discharge Slip

(To be handed'over to. patient / attendant)

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MCTS/RCH No.
Name of Facility ,\- I
IPD Registration No Lt Block

BPL Yes
.Z No District

Contact number
Art
Name & Mob
No. of ASHA {t?c'lity) ', .

Name: I n b.' fUt^, q, Age L4 Wo OR Dlo: M" -Ct \11

Full Address: 0
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qn i rD. a +". 9't ,I

Admissicn date 8r- t0. t l? Blood GrouprRh b

Discharge date: : I tl
Time
lo
Time tl
Provisronal Diagnosis: uru{ tL t n Diagnosis: r

with major ailments, if any

Deiivery date: rr- .7-

I
rime' I Y/6 p4"
Mo:le of Deliveny/ Procedure: Normal
i l--- T-
i Assisted I CS other (specify)
lndication for assisted/ LSCS/ Others 1 r- f-'
Delivery outcome: Live Slill birth
[] Sex of B Male Female a*:
Single Twinl Multiple Birth weigirt rn grams

Final outcome: Dischargel Referr.all Deah/ LAMA lmmunization: BGG E-oi,rl Qri"pB iJ
I H/o Birth Asphyxia: Ye$ No Apgar score at birth: t{}
lnjection Vitamin K,: Yes No Apgar score at 5 min. after birth:

Advice for ilother Advice for Baby

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Cot-S-r'; l q-1
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OtUr;- ^t-
a*ffia2 0vY",4,

Name and signature of setuic€ proyider: