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<b>
<span style=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>
De:</span>
</b>
<spanstyle=3D'font-size:10.0pt;font-family:"Tahoma","sans-serif"'>
 Formularios deGoogle [mailto:forms-receipts-noreply@google.com] <br>
<b>
Enviado el:</b>
 martes, 26 de marzo de 2019 10:55<br>
<b>
Para:</b>
 franciscasalinas@telemed-chile.cl<br>
<b>
Asunto:</b>
 Registro de Atenci=C3=B3n Domiciliaria Oncovida<o:p>
</o:p>
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</p>
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<p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
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<img id=3D"_x0000_i1025"  src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png"  alt=3D"Formularios de Google">
<o:p>
</o:p>
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<b>
<span style=3D'font-size:10.0pt;  color:#424242'>
Gracias por rellenar <a  href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link">
Registro  de Atenci=C3=B3n Domiciliaria Oncovida</a>
<o:p>
</o:p>
</span>
</b>
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Esto es lo que nos has enviado:<o:p>
</o:p>
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  <h1 style=3D'mso-margin-top-alt:8.05pt;margin-right:0cm;margin-bottom:8.05pt;  margin-left:0cm'>
Registro de Atenci=C3=B3n Domiciliaria Oncovida<o:p>
</o:p>
</h1>
  <div style=3D'margin-bottom:12.0pt;white-space:pre-wrap;word-wrap:break-word'>
  <p class=3DMsoNormal>
Este es el sistema de registro de atenciones domiciliarias  de Oncovida. Debe ser llenado por el prestador individual, y debe realizarse  un registro por cada visita domiciliaria. Si usted no es prestador de Oncovida  por favor no llene este formulario. A continuaci=C3=B3n indique su correo  electr=C3=B3nico.<o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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<b>
Direcci=C3=B3n de correo  electr=C3=B3nico <span class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
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  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
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<span  style=3D'color:#545454'>
franciscasalinas@telemed-chile.cl<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;max-width:100%'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <p class=3DMsoNormal align=3Dright style=3D'text-align:right;vertical-align:middle'>
<img  border=3D0 id=3D"_x0000_i1026"  src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ"  alt=3D"Imagen sin leyenda">
<o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
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Identificaci=C3=B3n del Prestador<o:p>
</o:p>
</h2>
  <div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
Aqu=C3=AD debe ingresar sus datos  personales<o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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<b>
Primer Nombre y Apellido  Paterno <span class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
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FRANCISCA SALINAS <o:p>
</o:p>
</span>
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<o:p>
&nbsp;</o:p>
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  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
RUT <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'margin-top:1.2pt;margin-bottom:3.0pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<span style=3D'color:#666666'>
RUT  con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)<o:p>
</o:p>
</span>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
16765876-8<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
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<b>
Tipo <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
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<span style=3D'color:#666666'>
Si  asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro  independiente<o:p>
</o:p>
</span>
</p>
  </div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[ENFERMERA/O&nbsp;\/] <o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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<img  border=3D0 id=3D"_x0000_i1027"  src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA"  alt=3D"Imagen sin leyenda">
<o:p>
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&nbsp;</o:p>
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Identificaci=C3=B3n del Paciente<o:p>
</o:p>
</h2>
  <div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
En esta secci=C3=B3n debe  ingresar los datos del paciente visitado<o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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Datos Personales del Paciente<o:p>
</o:p>
</h2>
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  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
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  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Ingrese el Rut del  Paciente <span class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'margin-top:1.2pt;margin-bottom:3.0pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<span style=3D'color:#666666'>
RUT  con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)<o:p>
</o:p>
</span>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
9295192-8<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
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  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Ingrese el Primer Nombre  y Apellido Paterno del Paciente <span class=3Dss-required-asterisk>
<span  style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
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  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
MARTA DE LA HOZ<o:p>
</o:p>
</span>
</p>
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  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
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  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Previsi=C3=B3n <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[DIPRECA&nbsp;\/] <o:p>
</o:p>
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<o:p>
&nbsp;</o:p>
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  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Ciudad <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
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CHILL=C3=81N<o:p>
</o:p>
</span>
</p>
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<o:p>
&nbsp;</o:p>
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<b>
Comuna <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
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CHILL=C3=81N<o:p>
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&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;max-width:100%'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <p class=3DMsoNormal align=3Dright style=3D'text-align:right;vertical-align:middle'>
<img  border=3D0 id=3D"_x0000_i1028"  src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ"  alt=3D"Imagen sin leyenda">
<o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <h2 style=3D'mso-margin-top-alt:24.0pt;margin-right:-4.8pt;margin-bottom:0cm;  margin-left:-4.8pt;margin-bottom:.0001pt;background:#EEEEEE;vertical-align:  middle'>
Registro de la Atenci=C3=B3n Domiciliaria<o:p>
</o:p>
</h2>
  <div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
En esta secci=C3=B3n debe  ingresar los datos de la atenci=C3=B3n domiciliaria<o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Tipo de Atenci=C3=B3n <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l0 level1 lfo1;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
(X)</span>
 <span  class=3Dss-choice-label>
Domicilio</span>
 <o:p>
</o:p>
</p>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l0 level1 lfo1;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
(&nbsp;)</span>
  <span class=3Dss-choice-label>
Ambulatorio</span>
 <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Fecha de la Atenci=C3=B3n <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div>
  <div style=3D'border:solid gainsboro 1.0pt;padding:0cm 0cm 0cm 2.0pt;  margin-left:2.25pt;margin-top:3.0pt;margin-right:2.25pt;margin-bottom:3.0pt;  min-height:32px;display:inline-block'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[25&nbsp;\/] [marzo&nbsp;\/]  [2019&nbsp;\/] <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Hora de la Atenci=C3=B3n <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div>
  <div style=3D'border:solid gainsboro 1.0pt;padding:0cm 0cm 0cm 2.0pt;  margin-left:2.25pt;margin-top:3.0pt;margin-right:2.25pt;margin-bottom:3.0pt;  min-height:32px;display:inline-block'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[17&nbsp;\/] : [00&nbsp;\/] <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Performance Status ECOG  del Paciente <span class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[4&nbsp;\/] <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;overflow-x:auto'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Escala Dolor EVA Actual <o:p>
</o:p>
</b>
</p>
  </div>
  <table class=3DMsoNormalTable border=3D0 cellspacing=3D0 cellpadding=3D0   id=3D"entry_1421689035">
   <tr>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
0<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
1<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
2<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
3<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
4<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
5<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
6<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
7<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
8<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
9<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
10<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
   </tr>
   <tr>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 0cm'>
</td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 3.0pt'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(X)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 0cm 6.0pt 3.0pt'>
</td>
   </tr>
  </table>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;overflow-x:auto'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Escala Dolor EVA M=C3=A1ximo <o:p>
</o:p>
</b>
</p>
  </div>
  <table class=3DMsoNormalTable border=3D0 cellspacing=3D0 cellpadding=3D0   id=3D"entry_1244707512">
   <tr>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
0<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
1<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
2<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
3<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
4<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
5<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
6<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
7<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
8<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
9<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
10<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
   </tr>
   <tr>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 0cm'>
</td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 3.0pt'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(X)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 0cm 6.0pt 3.0pt'>
</td>
   </tr>
  </table>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;overflow-x:auto'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Escala Dolor EVA M=C3=ADnimo <o:p>
</o:p>
</b>
</p>
  </div>
  <table class=3DMsoNormalTable border=3D0 cellspacing=3D0 cellpadding=3D0   id=3D"entry_853118630">
   <tr>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
0<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
1<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
2<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
3<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
4<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
5<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
6<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
7<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
8<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
9<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
10<o:p>
</o:p>
</p>
    </td>
    <td style=3D'padding:3.75pt 3.75pt 3.75pt 3.75pt'>
</td>
   </tr>
   <tr>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 0cm'>
</td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.0pt 6.0pt 3.0pt'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(X)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 3.75pt 6.0pt 0cm'>
    <div>
    <p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'>
<span    style=3D'color:#666666'>
(&nbsp;)<o:p>
</o:p>
</span>
</p>
    </div>
    </td>
    <td style=3D'border:solid #D3D8D3 1.0pt;padding:6.0pt 0cm 6.0pt 3.0pt'>
</td>
   </tr>
  </table>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Anamnesis/Evoluci=C3=B3n <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
PACIENTE EN BEG, CLOTE, TRAQUILA, CON DOLOR MODERADO EN  ZONA DE ESTOMA, QUE HA IDO DISMINUYENDO EN RELACI=C3=93N A LA VISITA DEL VIERNES  (EVA DE 4 PUNTOS). PACIENTE ENCAMADA MAS DEL 50% DEL D=C3=8DA. SE LEVANTA A COMER  Y PARA SUS TERAPIAS CON KINESI=C3=93LOGA. REQUIERE AYUDA PARA SATISFACER LA  MAYOR=C3=8DA DE LAS NECESIDADES B=C3=81SICAS. - NECESIDAD DE ALIMENTACI==C3=93N E  HIDRATACION: PACIENTE A COMENZADO A ALIMENTARSE DE FORMA NORMAL OTRA VEZ, YA  QUE EL DOLOR DEL ESTOMA A DISMINUIDO Y YA NO SIENTE TANTO TEMOR A ELIMINAR  MATERIA FECAL. -NECESIDAD DE MOVILIZARSE: PACIENTE CON SU EID AMPUTADA. SE  LEVANTA DE LA CAMA EN EL HORARIO DE LAS COMIDAS Y PARA REALIZAR SU TERAPIA  CON KINESI=C3=93LOGA. - ESCALA DE GLASGOW: 15 PUNTOS - ESCALA DE NORTON: 13 PUNTOS  - ESCALA DE DOWTON: 4 PUNTOS <o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Examen F=C3=ADsico <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
AL EXAMEN F=C3=8DSICO GENERAL, PACIENTE ENCAMADA, CON FACIE  TRANQUILA, CONSCIENTE, L=C3=9ACIDA, PIEL MUY DELICADA. PACIENTE PRESENTA  DERMATITIS EN VARIAS PARTES DEL CUERPO (DERMATITIS POR CONTACTO EN PIEL  CIRCUNDANTE AL ESTOMA, BRAZOS, ESPALDA, PECHO ASOCIADO AL USO DEL TRANSTEC).  ANEXOS EN BUENAS CONDICIONES. AL CONTROL DE SIGNOS VITALES, PACIENTE  HEMODINAMIC=C3=81MENTE ESTABLE, CON UNA PRESI=C3=93N DE 114/66 MMHG, NORMOC=C3=81RDICA (68  LPM) SATURANDO 98% CON FIO2 AMBIENTAL. AL EX=C3=81MEN F=C3=8DSICO SEGMENTARIO, DESTACA  LO MENCIONADO ANTERIORMENTE (DERMATITIS POR CONTACTO). ESTOMA EN MEJORES  CONDICIONES (HA DISMINUIDO EL DOLOR EN RELACI=C3=93N A LA =C3=9ALTIMA VISITA).<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Diagn=C3=B3stico <span  class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
CA PERITONEAL<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Plan de Tratamiento e  Indicaciones <span class=3Dss-required-asterisk>
<span style=3D'color:#C43B1D'>
*</span>
</span>
<o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
- CUIDADOS DE COLOSTOM=C3=8DA Y APLICACI=C3=93N DE CLOBETAZOL POR  DERMATITIS DE CONTACTO - PREVENCI=C3=93N DE CA=C3=8DDAS<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Medicamentos Indicados <o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'border:solid silver 1.0pt;padding:4.0pt 4.0pt 4.0pt 4.0pt;  max-width:90%;white-space:pre-wrap'>
  <p class=3DMsoNormal style=3D'background:#EEEEEE;vertical-align:middle'>
<span  style=3D'color:#545454'>
CLOBETAZOL 0.05% 2 VECES AL D=C3=8DA TRANSTEC 1 PARCHE CADA  3.5 D=C3=8DAS PREGABALINA DULOXETINA FAMOTIDINA<o:p>
</o:p>
</span>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Fecha aproximada del  Pr=C3=B3ximo Control con usted <o:p>
</o:p>
</b>
</p>
  </div>
  <div>
  <div style=3D'border:solid gainsboro 1.0pt;padding:0cm 0cm 0cm 2.0pt;  margin-left:2.25pt;margin-top:3.0pt;margin-right:2.25pt;margin-bottom:3.0pt;  min-height:32px;display:inline-block'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
[1&nbsp;\/] [abril&nbsp;\/] [2019&nbsp;\/]  <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Tratamiento Realizado (si  corresponde) <o:p>
</o:p>
</b>
</p>
  </div>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <div style=3D'margin-top:9.95pt;margin-bottom:9.95pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<b>
Derivaci=C3=B3n a otro  Prestador Domiciliario <o:p>
</o:p>
</b>
</p>
  </div>
  <div style=3D'margin-top:1.2pt;margin-bottom:3.0pt'>
  <p class=3DMsoNormal style=3D'vertical-align:middle'>
<span style=3D'color:#666666'>
S=C3=B3lo  llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del  equipo<o:p>
</o:p>
</span>
</p>
  </div>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l1 level1 lfo2;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
[&nbsp;]</span>
  <span class=3Dss-choice-label>
ENFERMERA</span>
 <o:p>
</o:p>
</p>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l1 level1 lfo2;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
[&nbsp;]</span>
  <span class=3Dss-choice-label>
TENS</span>
 <o:p>
</o:p>
</p>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l1 level1 lfo2;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
[&nbsp;]</span>
  <span class=3Dss-choice-label>
NUTRICIONISTA</span>
 <o:p>
</o:p>
</p>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l1 level1 lfo2;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
[&nbsp;]</span>
  <span class=3Dss-choice-label>
KINESIOLOGO</span>
 <o:p>
</o:p>
</p>
  <p class=3DMsoNormal style=3D'margin-left:0cm;text-indent:-18.0pt;line-height:  15.6pt;mso-list:l1 level1 lfo2;vertical-align:middle'>
<![if !supportLists]>
<span  style=3D'font-size:10.0pt;font-family:Symbol'>
<span style=3D'mso-list:Ignore'>
=C2=B7<span  style=3D'font:7.0pt "Times New Roman"'>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;  </span>
</span>
</span>
<![endif]>
<span class=3Dss-choice-item-control>
[&nbsp;]</span>
  <span class=3Dss-choice-label>
PSICOLOGO</span>
 <o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  <p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
  <div>
  <div style=3D'margin-top:9.0pt;margin-bottom:9.0pt;max-width:100%'>
  <div style=3D'margin-bottom:18.0pt;max-width:100%'>
  <p class=3DMsoNormal align=3Dright style=3D'text-align:right;vertical-align:middle'>
<img  border=3D0 id=3D"_x0000_i1029"  src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A"  alt=3D"Imagen sin leyenda">
<o:p>
</o:p>
</p>
  </div>
  </div>
  </div>
  </div>
  </div>
  </td>
 </tr>
 <tr>
  <td style=3D'padding:0cm 0cm 0cm 0cm'>
</td>
 </tr>
</table>
</div>
</div>
<div align=3Dcenter>
<table class=3DMsoNormalTable border=3D0 cellspacing=3D0 cellpadding=3D0 width=3D"100%" style=3D'width:100.0%'>
 <tr>
  <td style=3D'padding:0cm 0cm 0cm 0cm'>
</td>
 </tr>
 <tr>
  <td style=3D'padding:0cm 0cm 0cm 0cm'>
  <p class=3DMsoNormal>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link">
<span  style=3D'font-size:10.0pt;color:#424242'>
Crea tu propio formulario de Google</span>
</a>
<o:p>
</o:p>
</p>
  </td>
 </tr>
</table>
</div>
<p class=3DMsoNormal>
<o:p>
&nbsp;</o:p>
</p>
</div>
</div>
<div id=3D"DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2">
<br />
<br />
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<table style=3D'border-collapse:collapse;border:none;'>
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			<a href=3D"https://www.avast.com/antivirus">
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				El software de antivirus Avast ha analizado este correo electr=C3=B3nico en busca de virus.				<br>
<a href=3D"https://www.avast.com/antivirus">
www.avast.com</a>
			</p>
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