Transport and Discharge Request

Transport Request to:  [text name="variable_1" default="sample text"]

Hi team, I appreciate all of your hard work!  Here is a transport request! 

Patient Name
[text name="variable_2" default="Patient Name"]

Location: D1

Patient Address
[textarea name="variable_1" default="sample text"]

Requested Date and Time: [textarea name="variable_2" default="sample text"]

Notes:  [textarea name="variable_3" default=" "]


Discharge Request: 

[text name="variable_2" default="Patient Name"]  on D1

Transportation Requested / confirmed:  [textarea name="variable_5" default="sample text"]

Date and time requested: [textarea name="variable_6" default="sample text"]

Clinical CCP Status: [checkbox name="variable_1" value="Complete|Pending|Drafted"]

Discharge Status: [checkbox name="variable_2" value="Detox Complete| AA| Other"]
Transport Request to:

Hi team, I appreciate all of your hard work! Here is a transport request!

Patient Name


Location: D1

Patient Address


Requested Date and Time:

Notes:


Discharge Request:

on D1

Transportation Requested / confirmed:

Date and time requested:

Clinical CCP Status:

Discharge Status:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.2, 10 form elements, 44 boilerplate words, 3 text boxes, 5 text areas, 2 checkboxes, 14 total clicks
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