Transfer Out Form

Questions	Concepts
Receiving Facility __________________________________	162724 Health facility name
Transfer-Out Date (Date transfer-out takes effect) ␣␣-␣␣-␣␣␣␣ 📆	160649 Date transferred out
Transfer-out Verified*** 🔘 Yes 🔘 No 🔘 Unknown	VerificationDone Verification Complete 797e0073-1f3f-46b1-8b1a-8cdad134d2b3 1065 Yes 1066 No 1067 Unknown
Date verification done ␣␣-␣␣-␣␣␣␣ 📆	160753 Date of event
Notes __________________________________	165095 General patient note