Treatment Date Picker

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This field is for validation purposes and should be left unchanged.
One day after the treatment date indicated on this form, the patient will receive a Care Message that will prompt them to take the “How Are You Doing?” survey. Every Wednesday, starting one day after the indicated treatment date, they will receive a Care Message that prompts them to rate their distress on a scale from 0 to 10 (0 being no distress and 10 being extreme distress).
Patient Name*
First Last
Date of Birth*
Month
Day
Year
MR #*
Treatment Date*
MM slash DD slash YYYY
Submitted By*
First Last

[DEMO] ConciergeTreatment Date Picker