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Submitted URL: https://r20.rs6.net/tn.jsp?f=001pZnjQBptSmmcfox0Wp2yu--IcqBIHYbnWeEHVROrY3FurQ7UYQjB3ZiWS3gGuaN10HyhkXGMbVVzdhgBLv63...
Effective URL: https://app.smartsheet.com/b/form/6fc33aeec08d450c895fbdfc15dc7c32
Submission: On September 02 via manual from US
Effective URL: https://app.smartsheet.com/b/form/6fc33aeec08d450c895fbdfc15dc7c32
Submission: On September 02 via manual from US
Form analysis 1 forms found in the DOM
<form>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient First Name" data-client-type="text" id="kn2dNMQ" class="css-12ees97 ef83ajd0"><label for="text_box_Patient First Name" data-client-id="label_Patient First Name" class="css-1ilwm46 ekxsfat0">Patient First
Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Patient First Name" data-client-id="text_box_Patient First Name" data-client-type="" name="kn2dNMQ" maxlength="4000" class="css-bhxjq8 e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient Last Name" data-client-type="text" id="3AYWR75" class="css-12ees97 ef83ajd0"><label for="text_box_Patient Last Name" data-client-id="label_Patient Last Name" class="css-1ilwm46 ekxsfat0">Patient Last
Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Patient Last Name" data-client-id="text_box_Patient Last Name" data-client-type="" name="3AYWR75" maxlength="4000" class="css-bhxjq8 e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient DOB" data-client-type="date" id="wn7E5zk" class="css-1i71jyl ef83ajd0"><label for="date_Patient DOB" data-client-id="label_Patient DOB" class="css-1ilwm46 ekxsfat0">Patient DOB<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div></div>
<div class="css-1f92r3b"><input data-client-id="date_Patient DOB" id="date_Patient DOB" aria-label="Patient DOB" tabindex="0" name="Patient DOB" maxlength="100" class="css-tc7dpb epidubd0" value=""><button tabindex="0" type="button"
aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
<rect width="13" height="13" x="2" y="2" fill="#005EE0" rx="1"></rect>
<path fill="#FFF"
d="M11.648 12h-.96V8.38c-.351.328-.765.571-1.241.728v-.871c.25-.082.523-.238.817-.467.294-.229.495-.496.605-.801h.779V12zm-6.385-1.33l.93-.112c.03.237.11.418.24.543.129.125.286.188.47.188a.648.648 0 0 0 .502-.226c.135-.15.203-.353.203-.608 0-.241-.065-.433-.195-.574a.621.621 0 0 0-.475-.212c-.123 0-.27.024-.44.072l.105-.783c.26.007.458-.05.595-.17a.602.602 0 0 0 .205-.476.545.545 0 0 0-.15-.403.54.54 0 0 0-.4-.15.579.579 0 0 0-.42.17c-.117.114-.188.28-.213.5l-.885-.151c.061-.303.154-.545.279-.726.124-.182.297-.324.52-.428.221-.103.47-.155.746-.155.472 0 .85.15 1.135.45.234.247.352.525.352.835 0 .44-.24.79-.721 1.053.287.061.516.199.688.413a1.2 1.2 0 0 1 .258.776c0 .44-.16.815-.482 1.125-.32.31-.72.464-1.2.464-.453 0-.829-.13-1.127-.39a1.538 1.538 0 0 1-.52-1.025zM11 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2zM6 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2z">
</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient Email" data-client-type="text" id="YbwjYEm" class="css-12ees97 ef83ajd0"><label for="text_box_Patient Email" data-client-id="label_Patient Email" class="css-1ilwm46 ekxsfat0">Patient Email<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Patient Email" data-client-id="text_box_Patient Email" data-client-type="EMAIL" name="YbwjYEm" maxlength="4000" class="css-bhxjq8 e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient Mobile Phone #" data-client-type="text" id="wn7n0lO" class="css-12ees97 ef83ajd0"><label for="text_box_Patient Mobile Phone #" data-client-id="label_Patient Mobile Phone #"
class="css-1ilwm46 ekxsfat0">Patient Mobile Phone #</label>
<div style="display: flex;">
<div class=" react-tel-input" style="height: 35px; width: 40px;">
<div class="special-label">Phone</div><input class=" form-control" placeholder="1 (702) 123-4567" type="tel" name="wn7n0lO" aria-hidden="true" aria-label="phone picker" value="+1" style="display: none;">
<div class=" flag-dropdown">
<div class="selected-flag" title="United States: + 1" tabindex="0" role="button" aria-haspopup="listbox">
<div class="flag us">
<div class="arrow"></div>
</div>
</div>
</div>
</div><input aria-invalid="false" tabindex="0" id="text_box_Patient Mobile Phone #" data-client-id="text_box_Patient Mobile Phone #" data-client-type="PHONE" type="text" value="+1 (___) ___-____" inputmode="numeric">
</div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="container_Patient Home #" data-client-type="text" id="bGLApYK" class="css-12ees97 ef83ajd0"><label for="text_box_Patient Home #" data-client-id="label_Patient Home #" class="css-1ilwm46 ekxsfat0">Patient Home #</label>
<div style="display: flex;">
<div class=" react-tel-input" style="height: 35px; width: 40px;">
<div class="special-label">Phone</div><input class=" form-control" placeholder="1 (702) 123-4567" type="tel" name="bGLApYK" aria-hidden="true" aria-label="phone picker" value="+1" style="display: none;">
<div class=" flag-dropdown">
<div class="selected-flag" title="United States: + 1" tabindex="0" role="button" aria-haspopup="listbox">
<div class="flag us">
<div class="arrow"></div>
</div>
</div>
</div>
</div><input aria-invalid="false" tabindex="0" id="text_box_Patient Home #" data-client-id="text_box_Patient Home #" data-client-type="PHONE" type="text" value="+1 (___) ___-____" inputmode="numeric">
</div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div role="application" title="" data-client-id="container_DHAT Physician" data-client-type="dropdown" id="zn2Gpz8" class="css-y1zob4 ef83ajd0"><label for="select_input_DHAT Physician" id="2645c13e-73cb-4bee-9c67-5f615aa2c62b"
data-client-id="label_DHAT Physician" class="css-1ilwm46 ekxsfat0">DHAT Physician<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_DHAT Physician" spellcheck="false" tabindex="0" type="text" aria-label="Select"
aria-labelledby="2645c13e-73cb-4bee-9c67-5f615aa2c62b" value="" style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-1kp8wd8 e1tmc1mx0">
<div data-client-id="container_Name of DHAT Physician Not Listed above" data-client-type="text" id="89Yjy0k" class="css-12ees97 ef83ajd0"><label for="text_box_Name of DHAT Physician Not Listed above"
data-client-id="label_Name of DHAT Physician Not Listed above" class="css-1ilwm46 ekxsfat0">Name of DHAT Physician Not Listed above</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Name of DHAT Physician Not Listed above" data-client-id="text_box_Name of DHAT Physician Not Listed above" data-client-type="" name="89Yjy0k"
maxlength="4000" class="css-bhxjq8 e1407lhe0" value=""></div>
</div>
</div>
<div class="css-mhadp e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1hhcnvi excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1kpwj30">
<div>
<div>
<div class="grecaptcha-badge" data-style="bottomright"
style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LfbDqAUAAAAAPc856qavjKSEVbYbOIj3lAb2x3l&co=aHR0cHM6Ly9hcHAuc21hcnRzaGVldC5jb206NDQz&hl=en&type=image&v=Q_rrUPkK1sXoHi4wbuDTgcQR&theme=light&size=invisible&badge=bottomright&cb=85l49agq1hhy"
width="256" height="60" role="presentation" name="a-yacqk7p8n6bf" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-1sdhtps e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-1c2dpxk e8i4qwl0">
<div class="css-1kw6mnl e8i4qwl1">
<div class="css-qoiejo e8i4qwl3"><span>Powered by
</span><a target="_blank" href="https://www.smartsheet.com/platform?s=154" rel="noopener noreferrer" data-client-id="footer_poweredBy" aria-label="logo" class="css-a7ff3e e8i4qwl2"><svg role="img" xmlns="http://www.w3.org/2000/svg" version="1.1" width="80" height="35" viewBox="0 -55 406 179" style="margin-top: 2px; margin-left: 5px;"><title id="smartsheet-modern-logo-light">Smartsheet Modern Logo On Light</title><path fill="#003059" d="M85.4,29.7c-0.8-0.9-1.7-1.7-2.8-2.3c-1.2-0.6-2.6-1-4-0.9c-1.4,0-2.7,0.3-3.9,0.9c-1,0.5-1.7,1.6-1.6,2.7 c0,0.9,0.3,1.7,1,2.3c0.6,0.6,1.4,1.1,2.2,1.4c0.9,0.4,1.8,0.7,2.8,0.8l2.5,0.5c1.3,0.3,2.6,0.7,3.8,1.2c1.1,0.4,2.2,1,3.1,1.8 c0.9,0.7,1.5,1.7,2,2.7c0.5,1.2,0.8,2.5,0.7,3.9c0,1.7-0.4,3.3-1.2,4.7c-0.8,1.3-1.8,2.4-3.1,3.2c-1.3,0.9-2.8,1.5-4.3,1.8 c-1.6,0.4-3.2,0.6-4.9,0.5c-2.5,0.1-4.9-0.4-7.2-1.2c-2.2-1-4.2-2.5-5.6-4.6l4.8-3.9c1,1,2.2,1.9,3.4,2.7c1.4,0.8,3,1.2,4.6,1.2 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