Questions | Concepts | |
|---|---|---|
Visit Date ␣␣-␣␣-␣␣␣␣ 📆 | ||
Receiving Facility __________________________________ | ||
Transfer-Out Date (Date transfer-out takes effect) ␣␣-␣␣-␣␣␣␣ 📆 | ||
Transfer-out Verified 🔘 Yes 🔘 No 🔘 Unknown | ||
Date verification done ␣␣-␣␣-␣␣␣␣ 📆 | ||
Notes __________________________________ | ||
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