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<b>
De:</b>
 Formularios de Google &lt;forms-receipts-noreply@google.com&gt;<br>
<b>
Enviado:</b>
 viernes, 26 de abril de 2019 9:05 a.m.<br>
<b>
Para:</b>
 abdul2508@hotmail.com<br>
<b>
Asunto:</b>
 Registro de Atenci=F3n Domiciliaria Oncovida</font>
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&nbsp;</div>
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<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"background-color:rgb(38,4,154)">
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<img alt=3D"Formularios de Google" height==3D"26px" width=3D"143px" style=3D"display:inline-block; margin:0; vertical-align:middle" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
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</tbody>
</table>
<div style=3D"padding:24px; background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:#fff; border-bottom:1px solid #e0e0e0; margin:0 auto; max-width:624px; min-width:154px; padding:0 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"background-color:#fff">
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<div style=3D"font-size:13px; line-height:18px; color:#424242; font-weight:700">
Gracias por rellenar<a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link">
Registro de Atenci=F3n Domiciliaria Oncovida</a>
</div>
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<tr height=3D"12px">
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<div style=3D"font-size:13px; line-height:18px; color:#424242">
Esto es lo que nos has enviado:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"ss-form-container" style=3D"">
<div class=3D"ss-form-heading" style=3D"">
<h1 class=3D"ss-form-title" dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=F3n Domiciliaria Oncovida</h1>
<div class=3D"ss-form-desc ss-no-ignore-whitespace" style=3D"font:inherit; width:99%; margin:0 0 1em; white-space:pre-wrap; word-wrap:break-word">
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=F3n indique su correo electr=F3nico.</div>
</div>
<div class=3D"ss-form" style=3D"">
<form action=3D"" method=3D"GET" id=3D"ss-form" style=3D"">
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"emailAddress" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Direcci=F3n de correo electr=F3nico <label for=3D"emailAddress" aria-label==3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div class=3D"ss-q-text ss-printable-text-line" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
abdul2508@hotmail.com</div>
</div>
</div>
</div>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Prestador</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
Aqu=ED debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_579114469" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Primer Nombre y Apellido Paterno <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
abdul sarria</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1276273985" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
RUT <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
26743483-2</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_133691676" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled=3D"" id=3D"entry_133691676" aria-label=3D"Tipo Si asisten m=E1s de 1 prestador simult=E1neamente, cada uno debe hacer un registro independiente " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"MEDICO" disabled=3D"" selected=3D"" style=3D"">
MEDICO</option>
<option value=3D"ENFERMERA/O" disabled=3D"" style=3D"">
ENFERMERA/O</option>
 <option value=3D"TENS" disabled=3D"" style=3D"">
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled=3D"" style=3D"">
KINESIOLOGA/O</option>
<option value=3D"PSICOLOGO" disabled=3D"" style=3D"">
PSICOLOGO</option>
 <option value=3D"NUTRICIONISTA" disabled=3D"" style=3D"">
NUTRICIONISTA</option>
</select>
 </div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Identificaci=F3n del Paciente</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-section-header" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-section-title" style=3D"background-color:#eee; padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"ss-section-description ss-no-ignore-whitespace" style=3D"margin-top:0.5em; white-space:pre-wrap; word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_823811303" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ingrese el Rut del Paciente <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
RUT con Gui=F3n y D=EDgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
7966839-7</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1959365839" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
jose leyva </div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-select" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_545002227" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Previsi=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled=3D"" id=3D"entry_545002227" aria-label=3D"Previsi=F3n  " style=3D"">
<option value=3D"" style=3D"">
</option>
 <option value=3D"BANMEDICA" disabled=3D"" style=3D"">
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled=3D"" style=3D"">
CAPREDENA</option>
 <option value=3D"COLMENA" disabled=3D"" style=3D"">
COLMENA</option>
 <option value=3D"CONSALUD" disabled=3D"" selected=3D"" style=3D"">
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled=3D"" style=3D"">
CRUZ BLANCA</option>
<option value=3D"DIPRECA" disabled=3D"" style=3D"">
DIPRECA</option>
 <option value=3D"FONASA" disabled=3D"" style=3D"">
FONASA</option>
 <option value=3D"FUNDACION" disabled=3D"" style=3D"">
FUNDACION</option>
<option value=3D"ISAPRES DEL COBRE" disabled=3D"" style=3D"">
ISAPRES DEL COBRE</option>
<option value=3D"NUEVA MASVIDA" disabled=3D"" style=3D"">
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled=3D"" style=3D"">
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled=3D"" style=3D"">
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1900161356" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Ciudad <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
antofagasta</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-text" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1298871758" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Comuna <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-text" dir=3D"auto" style=3D"background-color:#eee; max-width:90%; border:1px solid #c0c0c0; padding:5px; white-space:pre-wrap; color:#545454; width:70%">
ntofagasta</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-embeddable-object-container" style==3D"margin:12px 0; max-width:100%">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ">
</div>
</div>
</div>
</div>
<br>
<div class=3D"errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item  ss-page-break" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<h2 class=3D"ss-page-title" style=3D"padding:0.4em; background-color:#eee">
Registro de la Atenci=F3n Domiciliaria</h2>
<div class=3D"ss-page-description ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap; word-wrap:break-word">
En esta secci=F3n debe ingresar los datos de la atenci=F3n domiciliaria</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-radio" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_2073233714" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tipo de Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<ul class=3D"ss-choices" role=3D"radiogroup" aria-label=3D"Tipo de Atenci==F3n  " style=3D"list-style:none; padding:0; margin:.5em 0 0">
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" checked=3D"" value=3D"Domicilio" id=3D"group_1222378237_1" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Domicilio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Domicilio</span>
 </label>
</li>
<li class=3D"ss-choice-item" style=3D"margin:0; line-height:1.3em; padding-bottom:.5em">
<label>
<span class=3D"ss-choice-item-control goog-inline-block" style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled=3D"" value=3D"Ambulatorio" id=3D"group_1222378237_2" role=3D"radio" class=3D"ss-q-radio" aria-label=3D"Ambulatorio" style=3D"">
</span>
<span class=3D"ss-choice-label" style=3D"">
Ambulatorio</span>
 </label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-date" style=3D"margin:12px 0">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_1705849412" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha de la Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label=3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha de la Atenci=F3n  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
<select name=3D"entry.1705849412_day" disabled=3D"" class=3D"ss-day-dropdown" id=3D"entry.1705849412_day" aria-label=3D"D=EDa del mes" style=3D"">
<option value=3D"" style=3D"">
D=EDa</option>
 <option value=3D"1" style=3D"">
1</option>
 <option value=3D"2" style=3D"">
2</option>
<option value=3D"3" style=3D"">
3</option>
 <option value=3D"4" style=3D"">
4</option>
 <option value=3D"5" style=3D"">
5</option>
 <option value=3D"6" style=3D"">
6</option>
 <option value=3D"7" style=3D"">
7</option>
<option value=3D"8" style=3D"">
8</option>
 <option value=3D"9" style=3D"">
9</option>
 <option value=3D"10" style=3D"">
10</option>
 <option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
 <option value=3D"21" style=3D"">
21</option>
<option value=3D"22" style=3D"">
22</option>
 <option value=3D"23" style=3D"">
23</option>
 <option value=3D"24" style=3D"">
24</option>
 <option value=3D"25" selected=3D"" style=3D"">
25</option>
 <option value=3D"26" style=3D"">
26</option>
 <option value=3D"27" style=3D"">
27</option>
 <option value=3D"28" style=3D"">
28</option>
 <option value=3D"29" style=3D"">
29</option>
 <option value=3D"30" style=3D"">
30</option>
<option value=3D"31" style=3D"">
31</option>
</select>
 <select name=3D"entry.1705849412_month" disabled=3D"" class=3D"ss-month-dropdown" id=3D"entry.1705849412_month" aria-label=3D"Mes" style=3D"">
<option value=3D"" style=3D"">
Mes</option>
 <option value=3D"1" style=3D"">
enero</option>
 <option value=3D"2" style=3D"">
febrero</option>
 <option value=3D"3" style=3D"">
marzo</option>
 <option value=3D"4" selected=3D"" style=3D"">
abril</option>
 <option value=3D"5" style=3D"">
mayo</option>
 <option value==3D"6" style=3D"">
junio</option>
 <option value=3D"7" style=3D"">
julio</option>
 <option value==3D"8" style=3D"">
agosto</option>
 <option value=3D"9" style=3D"">
septiembre</option>
 <option value=3D"10" style=3D"">
octubre</option>
 <option value=3D"11" style=3D"">
noviembre</option>
 <option value=3D"12" style=3D"">
diciembre</option>
</select>
 <select name=3D"entry.1705849412_year" disabled=3D"" id=3D"entry.1705849412_year" aria-label=3D"A=F1o" style=3D"">
<option value=3D"" style=3D"">
A=F1o</option>
 <option value=3D"1896" style=3D"">
1896</option>
 <option value=3D"1897" style=3D"">
1897</option>
 <option value=3D"1898" style=3D"">
1898</option>
 <option value=3D"1899" style=3D"">
1899</option>
 <option value=3D"1900" style=3D"">
1900</option>
 <option value=3D"1901" style=3D"">
1901</option>
 <option value=3D"1902" style=3D"">
1902</option>
 <option value=3D"1903" style=3D"">
1903</option>
 <option value=3D"1904" style=3D"">
1904</option>
 <option value=3D"1905" style=3D"">
1905</option>
 <option value=3D"1906" style=3D"">
1906</option>
 <option value=3D"1907" style=3D"">
1907</option>
 <option value=3D"1908" style=3D"">
1908</option>
 <option value=3D"1909" style=3D"">
1909</option>
 <option value=3D"1910" style=3D"">
1910</option>
 <option value=3D"1911" style=3D"">
1911</option>
 <option value=3D"1912" style=3D"">
1912</option>
 <option value=3D"1913" style=3D"">
1913</option>
 <option value=3D"1914" style=3D"">
1914</option>
 <option value=3D"1915" style=3D"">
1915</option>
 <option value=3D"1916" style=3D"">
1916</option>
 <option value=3D"1917" style=3D"">
1917</option>
 <option value=3D"1918" style=3D"">
1918</option>
 <option value=3D"1919" style=3D"">
1919</option>
 <option value=3D"1920" style=3D"">
1920</option>
 <option value=3D"1921" style=3D"">
1921</option>
 <option value=3D"1922" style=3D"">
1922</option>
 <option value=3D"1923" style=3D"">
1923</option>
 <option value=3D"1924" style=3D"">
1924</option>
 <option value=3D"1925" style=3D"">
1925</option>
 <option value=3D"1926" style=3D"">
1926</option>
 <option value=3D"1927" style=3D"">
1927</option>
 <option value=3D"1928" style=3D"">
1928</option>
 <option value=3D"1929" style=3D"">
1929</option>
 <option value=3D"1930" style=3D"">
1930</option>
 <option value=3D"1931" style=3D"">
1931</option>
 <option value=3D"1932" style=3D"">
1932</option>
 <option value=3D"1933" style=3D"">
1933</option>
 <option value=3D"1934" style=3D"">
1934</option>
 <option value=3D"1935" style=3D"">
1935</option>
 <option value=3D"1936" style=3D"">
1936</option>
 <option value=3D"1937" style=3D"">
1937</option>
 <option value=3D"1938" style=3D"">
1938</option>
 <option value=3D"1939" style=3D"">
1939</option>
 <option value=3D"1940" style=3D"">
1940</option>
 <option value=3D"1941" style=3D"">
1941</option>
 <option value=3D"1942" style=3D"">
1942</option>
 <option value=3D"1943" style=3D"">
1943</option>
 <option value=3D"1944" style=3D"">
1944</option>
 <option value=3D"1945" style=3D"">
1945</option>
 <option value=3D"1946" style=3D"">
1946</option>
 <option value=3D"1947" style=3D"">
1947</option>
 <option value=3D"1948" style=3D"">
1948</option>
 <option value=3D"1949" style=3D"">
1949</option>
 <option value=3D"1950" style=3D"">
1950</option>
 <option value=3D"1951" style=3D"">
1951</option>
 <option value=3D"1952" style=3D"">
1952</option>
 <option value=3D"1953" style=3D"">
1953</option>
 <option value=3D"1954" style=3D"">
1954</option>
 <option value=3D"1955" style=3D"">
1955</option>
 <option value=3D"1956" style=3D"">
1956</option>
 <option value=3D"1957" style=3D"">
1957</option>
 <option value=3D"1958" style=3D"">
1958</option>
 <option value=3D"1959" style=3D"">
1959</option>
 <option value=3D"1960" style=3D"">
1960</option>
 <option value=3D"1961" style=3D"">
1961</option>
 <option value=3D"1962" style=3D"">
1962</option>
 <option value=3D"1963" style=3D"">
1963</option>
 <option value=3D"1964" style=3D"">
1964</option>
 <option value=3D"1965" style=3D"">
1965</option>
 <option value=3D"1966" style=3D"">
1966</option>
 <option value=3D"1967" style=3D"">
1967</option>
 <option value=3D"1968" style=3D"">
1968</option>
 <option value=3D"1969" style=3D"">
1969</option>
 <option value=3D"1970" style=3D"">
1970</option>
 <option value=3D"1971" style=3D"">
1971</option>
 <option value=3D"1972" style=3D"">
1972</option>
 <option value=3D"1973" style=3D"">
1973</option>
 <option value=3D"1974" style=3D"">
1974</option>
 <option value=3D"1975" style=3D"">
1975</option>
 <option value=3D"1976" style=3D"">
1976</option>
 <option value=3D"1977" style=3D"">
1977</option>
 <option value=3D"1978" style=3D"">
1978</option>
 <option value=3D"1979" style=3D"">
1979</option>
 <option value=3D"1980" style=3D"">
1980</option>
 <option value=3D"1981" style=3D"">
1981</option>
 <option value=3D"1982" style=3D"">
1982</option>
 <option value=3D"1983" style=3D"">
1983</option>
 <option value=3D"1984" style=3D"">
1984</option>
 <option value=3D"1985" style=3D"">
1985</option>
 <option value=3D"1986" style=3D"">
1986</option>
 <option value=3D"1987" style=3D"">
1987</option>
 <option value=3D"1988" style=3D"">
1988</option>
 <option value=3D"1989" style=3D"">
1989</option>
 <option value=3D"1990" style=3D"">
1990</option>
 <option value=3D"1991" style=3D"">
1991</option>
 <option value=3D"1992" style=3D"">
1992</option>
 <option value=3D"1993" style=3D"">
1993</option>
 <option value=3D"1994" style=3D"">
1994</option>
 <option value=3D"1995" style=3D"">
1995</option>
 <option value=3D"1996" style=3D"">
1996</option>
 <option value=3D"1997" style=3D"">
1997</option>
 <option value=3D"1998" style=3D"">
1998</option>
 <option value=3D"1999" style=3D"">
1999</option>
 <option value=3D"2000" style=3D"">
2000</option>
 <option value=3D"2001" style=3D"">
2001</option>
 <option value=3D"2002" style=3D"">
2002</option>
 <option value=3D"2003" style=3D"">
2003</option>
 <option value=3D"2004" style=3D"">
2004</option>
 <option value=3D"2005" style=3D"">
2005</option>
 <option value=3D"2006" style=3D"">
2006</option>
 <option value=3D"2007" style=3D"">
2007</option>
 <option value=3D"2008" style=3D"">
2008</option>
 <option value=3D"2009" style=3D"">
2009</option>
 <option value=3D"2010" style=3D"">
2010</option>
 <option value=3D"2011" style=3D"">
2011</option>
 <option value=3D"2012" style=3D"">
2012</option>
 <option value=3D"2013" style=3D"">
2013</option>
 <option value=3D"2014" style=3D"">
2014</option>
 <option value=3D"2015" style=3D"">
2015</option>
 <option value=3D"2016" style=3D"">
2016</option>
 <option value=3D"2017" style=3D"">
2017</option>
 <option value=3D"2018" style=3D"">
2018</option>
 <option value=3D"2019" selected=3D"" style=3D"">
2019</option>
 <option value=3D"2020" style=3D"">
2020</option>
 <option value=3D"2021" style=3D"">
2021</option>
 <option value=3D"2022" style=3D"">
2022</option>
 <option value=3D"2023" style=3D"">
2023</option>
 <option value=3D"2024" style=3D"">
2024</option>
 <option value=3D"2025" style=3D"">
2025</option>
 <option value=3D"2026" style=3D"">
2026</option>
 <option value=3D"2027" style=3D"">
2027</option>
 <option value=3D"2028" style=3D"">
2028</option>
 <option value=3D"2029" style=3D"">
2029</option>
 <option value=3D"2030" style=3D"">
2030</option>
 <option value=3D"2031" style=3D"">
2031</option>
 <option value=3D"2032" style=3D"">
2032</option>
 <option value=3D"2033" style=3D"">
2033</option>
 <option value=3D"2034" style=3D"">
2034</option>
 <option value=3D"2035" style=3D"">
2035</option>
 <option value=3D"2036" style=3D"">
2036</option>
 <option value=3D"2037" style=3D"">
2037</option>
 <option value=3D"2038" style=3D"">
2038</option>
 <option value=3D"2039" style=3D"">
2039</option>
 <option value=3D"2040" style=3D"">
2040</option>
 <option value=3D"2041" style=3D"">
2041</option>
 <option value=3D"2042" style=3D"">
2042</option>
 <option value=3D"2043" style=3D"">
2043</option>
 <option value=3D"2044" style=3D"">
2044</option>
 <option value=3D"2045" style=3D"">
2045</option>
 <option value=3D"2046" style=3D"">
2046</option>
 <option value=3D"2047" style=3D"">
2047</option>
 <option value=3D"2048" style=3D"">
2048</option>
 <option value=3D"2049" style=3D"">
2049</option>
 <option value=3D"2050" style=3D"">
2050</option>
 <option value=3D"2051" style=3D"">
2051</option>
 <option value=3D"2052" style=3D"">
2052</option>
 <option value=3D"2053" style=3D"">
2053</option>
 <option value=3D"2054" style=3D"">
2054</option>
 <option value=3D"2055" style=3D"">
2055</option>
 <option value=3D"2056" style=3D"">
2056</option>
 <option value=3D"2057" style=3D"">
2057</option>
 <option value=3D"2058" style=3D"">
2058</option>
 <option value=3D"2059" style=3D"">
2059</option>
 <option value=3D"2060" style=3D"">
2060</option>
 <option value=3D"2061" style=3D"">
2061</option>
 <option value=3D"2062" style=3D"">
2062</option>
 <option value=3D"2063" style=3D"">
2063</option>
 <option value=3D"2064" style=3D"">
2064</option>
 <option value=3D"2065" style=3D"">
2065</option>
 <option value=3D"2066" style=3D"">
2066</option>
 <option value=3D"2067" style=3D"">
2067</option>
 <option value=3D"2068" style=3D"">
2068</option>
 <option value=3D"2069" style=3D"">
2069</option>
</select>
 </div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
<div dir=3D"auto" class=3D"ss-item ss-item-required ss-time" style=3D"margin:12px 0; font:inherit">
<div class=3D"ss-form-entry" style=3D"margin-bottom:1.5em; vertical-align:middle; margin-left:0; margin-top:0; max-width:100%">
<label class=3D"ss-q-item-label" for=3D"entry_206244955" style=3D"">
<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Hora de la Atenci=F3n <label for=3D"itemView.getDomIdToLabel()" aria-label==3D"(Campo obligatorio)" style=3D"">
</label>
<span class=3D"ss-required-asterisk" aria-hidden=3D"true" style=3D"color:#c43b1d">
*</span>
</div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
</div>
</label>
<div class=3D"ss-q-time" style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" dir=3D"ltr" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
<select name=3D"entry.206244955_hour" disabled=3D"" id=3D"entry.206244955_hour" aria-label=3D"Hora" style=3D"">
<option value=3D"" style=3D"">
h</option>
 <option value=3D"00" style=3D"">
00</option>
 <option value=3D"01" style=3D"">
01</option>
 <option value=3D"02" style=3D"">
02</option>
 <option value=3D"03" style=3D"">
03</option>
<option value=3D"04" style=3D"">
04</option>
 <option value=3D"05" style=3D"">
05</option>
 <option value=3D"06" style=3D"">
06</option>
 <option value=3D"07" style=3D"">
07</option>
 <option value=3D"08" style=3D"">
08</option>
 <option value=3D"09" style=3D"">
09</option>
 <option value=3D"10" style=3D"">
10</option>
<option value=3D"11" style=3D"">
11</option>
 <option value=3D"12" selected==3D"" style=3D"">
12</option>
 <option value=3D"13" style=3D"">
13</option>
 <option value=3D"14" style=3D"">
14</option>
<option value=3D"15" style=3D"">
15</option>
 <option value=3D"16" style=3D"">
16</option>
 <option value=3D"17" style=3D"">
17</option>
 <option value=3D"18" style=3D"">
18</option>
 <option value=3D"19" style=3D"">
19</option>
 <option value=3D"20" style=3D"">
20</option>
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Escala Dolor EVA Actual </div>
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Escala Dolor EVA M=E1ximo </div>
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1</label>
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2</label>
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3</label>
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4</label>
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5</label>
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6</label>
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7</label>
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8</label>
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9</label>
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10</label>
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<td class=3D"ss-scalenumbers" style=3D"text-align:center">
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<div aria-hidden=3D"true" class=3D"aria-todo" style=3D"">
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<td class=3D"ss-scalerow" style=3D"text-align:center; color:#666; border:1px solid #d3d8d3; border-left:0; border-right:0; padding:.5em .25em">
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se atiende llamado de enfermera refiriendo que paciente manifiesta sentirse con malestar agudo. paciente de 62 a=F1os de edad, hipertenso controlado, diabetico controlado, con dx de base CA de pr=F3stata con met=E1stasis en pulm=F3n en tto con quimioterapia doxetacel 75mg ev hasta el momento 6 sesiones sin mayores efectos secundarios ultima 16/4/2019, funcional en sus actividades cotidianas, con disnea de grandes esfuerzos, posterior a la quimioterapia aumentaron s=EDntomas de disfagia, odinofagia, acudio a urgencias sin complicaciones ni necesdiad de ATB, dando manejo con anti inflamatorios (actualmente tom=E1ndolos) realizando actividad laboral presenta quemadura en dorso de la mano derecha de 2 grado superficial de peque=F1o tama=F1o en proceso de cicatrizaci=F3n sin signos de sobreinfeccion, se encuentra paciente en cama, p=E1lido diafor=E9tico, somnoliento, manifestando hambre en exceso, signos vitales estables y reporte de HGT 64, cursando ahora con hipoglucemia, la esposa refiere que posterior a un &quot;susto&quot; por ca=EDda de estanter=EDa en el taller sin contusiones una hora antes de la visita vs sobredosis de insulina medicamento en horas de la ma=F1ana 30 nph mas 4 UI de cristalina mas dosis oral por glucemia de 250 en la ma=F1ana, niega s=EDntomas de alarma como fiebre frecuente, intolerancia a la v=EDa oral, perdida de peso, sudoraci=F3n nocturna, niega dolor tor==E1cico, niega otros s=EDntomas.</div>
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paciente luce palido, diaforetico, somnoliento, orientado en tiempo lugar y persona, acompa=F1ado de su esposa, colaborador, sin signos de dificultad respiratoria o dolor agudo, svt ta:144/77 sto 98% fc 82 fr 18 t 36g, HGT 64 mucosas hidratadas, escleras anictericas, conjuntivas rosadas, cuello no doloroso y m=F3vil no se palpan adenopatias considerables, cavidad oral sin alteraciones, ruidos card=EDacos r=EDtmicos y regulares no se auscultan soplos, campos pulmonares bien ventilados sin sobre agregados, abdomen blando deprensible no doloroso no se palpan masas, extremidades sim=E9tricas m=F3viles sin edemas ni equimosis, cateter en zona del clavicular derecha sin signos inflamatorios, y parche trastec en zona escapular izda, no hay dolor a la palpaci=F3n muscular, glasgow 15/15. con quemadura de 2 grado superficial en dorso de la mano derecha de peque=F1o tama=F1o sin mayores complicaciones en proceso de cicatrizaci=F3n.</div>
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1) HIPOGLICEMIA AGUDA 2) CA de prostata con metastasis a pulmon </div>
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se ordena iniciar via oral, ingerir jugos glucosados mas la conservaci=F3n de la temperatura, se espera aproximadamente 30 min donde reporte de nuevo HGT de control es 120 recuperando glicemia, se continua con via oral, el paciente mejora aspecto, cese de diaforesis, comunicacion mas fluida, activo, se educa sobre riesgos de hipoglicemia y dosis adecuadas de medicamentos de base para prevenir complicaciones, se deja paciente en cama reposando con indicacion de via oral, glicemia en horas de la noche, nueva dosis de insulina en horario nocturno, se dan sintomas y signos de alarma para acudir a urgencias ante la sospecha de un nuevo caso de hipoglicemia. se deja igual tto medico para el manejo del dolor.</div>
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Medicamentos Indicados </div>
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</div>
</label>
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paracetamol 1gr SOS tramadol 20gotas SOS igual dosis del trastec medio parche</div>
</div>
</div>
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<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Fecha aproximada del Pr=F3ximo Control con usted </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
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<div class=3D"ss-q-date" role=3D"group" aria-label=3D"Fecha aproximada del Pr=F3ximo Control con usted  " style=3D"">
<div class=3D"ss-datetime-box goog-inline-block" role=3D"group" style=3D"border:1px solid #dcdcdc; margin-right:2em; min-height:32px; padding-left:3px; vertical-align:middle; margin:4px 3px; display:inline-block">
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D=EDa</option>
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2</option>
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6</option>
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17</option>
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18</option>
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20</option>
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22</option>
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23</option>
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25</option>
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27</option>
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28</option>
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29</option>
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31</option>
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A=F1o</option>
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1896</option>
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1897</option>
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1898</option>
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1900</option>
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1907</option>
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1911</option>
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1914</option>
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1918</option>
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1920</option>
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1922</option>
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1923</option>
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1924</option>
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1925</option>
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1926</option>
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1927</option>
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1928</option>
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1929</option>
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1930</option>
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1931</option>
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1932</option>
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1933</option>
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1934</option>
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1935</option>
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1936</option>
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1937</option>
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1938</option>
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1939</option>
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1940</option>
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1941</option>
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1942</option>
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1943</option>
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1944</option>
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1945</option>
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1946</option>
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1947</option>
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1949</option>
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1950</option>
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1951</option>
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1952</option>
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1953</option>
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1954</option>
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1955</option>
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1956</option>
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1957</option>
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1958</option>
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1959</option>
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1960</option>
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1961</option>
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1962</option>
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1963</option>
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1964</option>
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1966</option>
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1967</option>
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1968</option>
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1969</option>
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1970</option>
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1971</option>
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1972</option>
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1973</option>
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1974</option>
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1975</option>
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1977</option>
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1981</option>
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1982</option>
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1986</option>
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1987</option>
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1988</option>
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1989</option>
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1990</option>
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1991</option>
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1992</option>
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1993</option>
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1994</option>
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1995</option>
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1996</option>
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1997</option>
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1998</option>
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1999</option>
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2000</option>
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2001</option>
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2002</option>
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2003</option>
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2004</option>
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2005</option>
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2006</option>
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2007</option>
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2008</option>
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2009</option>
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2010</option>
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2011</option>
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2012</option>
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2013</option>
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2014</option>
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2015</option>
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2016</option>
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2017</option>
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2018</option>
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2019</option>
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2020</option>
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2021</option>
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2022</option>
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2023</option>
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2024</option>
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2025</option>
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2026</option>
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2027</option>
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2028</option>
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2029</option>
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2030</option>
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2031</option>
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2032</option>
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2033</option>
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2034</option>
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2035</option>
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2036</option>
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2037</option>
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2038</option>
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2039</option>
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2040</option>
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2041</option>
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2042</option>
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2043</option>
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2044</option>
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2045</option>
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2046</option>
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2047</option>
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2048</option>
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2049</option>
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2050</option>
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2051</option>
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2052</option>
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2053</option>
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2054</option>
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2055</option>
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2056</option>
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2057</option>
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2058</option>
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2059</option>
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2060</option>
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2061</option>
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2062</option>
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2063</option>
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2064</option>
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2065</option>
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2066</option>
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2067</option>
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2068</option>
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2069</option>
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<div dir=3D"auto" class=3D"ss-item  ss-text" style=3D"margin:12px 0">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Tratamiento Realizado (si corresponde) </div>
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</div>
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correccion de hipoglicemia por via oral y medidas locales.</div>
</div>
</div>
</div>
<br>
<div class=3D"ss-form-question errorbox-good" role=3D"listitem" style=3D"">
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<div class=3D"ss-q-title" style=3D"display:block; font-weight:bold; margin-top:.83em; margin-bottom:.83em">
Derivaci=F3n a otro Prestador Domiciliario </div>
<div class=3D"ss-q-help ss-secondary-text" dir=3D"auto" style=3D"display:block; margin:.1em 0 .25em 0; color:#666">
S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo</div>
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<ul class=3D"ss-choices" role=3D"group" aria-label=3D"Derivaci=F3n a otro Prestador Domiciliario S=F3lo llene esta secci=F3n si es m=E9dico y solicita la visita de otro prestador del equipo " style=3D"list-style:none; padding:0; margin:.5em 0 0">
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ENFERMERA</span>
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TENS</span>
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NUTRICIONISTA</span>
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KINESIOLOGO</span>
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<label>
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PSICOLOGO</span>
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</h2>
<div style=3D"text-align:right">
<img class=3D"ss-image" title=3D"" alt=3D"Imagen sin leyenda" style=3D"width:78px; outline:none" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A">
</div>
</div>
</div>
</div>
<br>
</form>
</div>
</div>
</td>
</tr>
<tr height=3D"24px">
</tr>
</tbody>
</table>
</div>
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" role=3D"presentation" style=3D"max-width:672px; min-width:154px">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<a href=3D"https://docs.google.com/forms?usp=3Dmail_form_link" style=3D"color:#424242; font-size:13px">
Crea tu propio formulario de Google</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<div id=3D"DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2">
<br>
<table style=3D"border-top: 1px solid #D3D4DE;">
<tbody>
<tr>
<td style=3D"width: 55px; padding-top: 18px;">
<a href=3D"https://www.avast.com/sig-email?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank">
<img alt=3D"" width==3D"46" height=3D"29" style=3D"width: 46px; height: 29px;" src=3D"https://ipmcdn.avast.com/images/icons/icon-envelope-tick-round-orange-animated-no-repeat-v1.gif">
</a>
</td>
<td style=3D"width: 470px; padding-top: 17px; color: #41424e; font-size: 13px; font-family: Arial, Helvetica, sans-serif; line-height: 18px;">
Libre de virus. <a href=3D"https://www.avast.com/sig-email?utm_medium=3Demail&amp;utm_source=3Dlink&amp;utm_campaign=3Dsig-email&amp;utm_content=3Dwebmail" target=3D"_blank" style=3D"color: #4453ea;">
www.avast.com</a>
 </td>
</tr>
</tbody>
</table>
<a href=3D"#DAB4FAD8-2DD7-40BB-A1B8-4E2AA1F9FDF2" width=3D"1" height=3D"1">
</a>
</div>
</body>
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