<div dir=3D"ltr">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" style=3D"background-color:rgb(38,4,154)">
<tbody>
<tr height=3D"64px">
<td style=3D"padding-left:24px">
<img alt=3D"Google Forms" height=3D"26px" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png" class=3D"gmail-CToWUd" style=3D"display: inline-block; margin: 0px; vertical-align: middle;">
</td>
</tr>
</tbody>
</table>
<div style=3D"padding:24px;background-color:rgb(229,218,254)">
<div align=3D"center" style=3D"background-color:rgb(255,255,255);border-bottom:1px solid rgb(224,224,224);margin:0px auto;max-width:624px;min-width:154px;padding:0px 24px">
<table align=3D"center" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:rgb(66,66,66);font-weight:700">
Thanks for filling out=C2=A0<a href=3D"https://docs.google.com/forms/d/e/1FAIpQLSdEtSr7xXzExpMb4RkiyPWKMwg1WaFIAImkCVv7UFdpPco75w/viewform?usp=3Dmail_form_link" target=3D"_blank">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</a>
</div>
</td>
</tr>
<tr height=3D"12px">
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:rgb(66,66,66)">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div class=3D"gmail-m_5827365450680548321ss-form-container">
<span class=3D"gmail-im" style=3D"color:rgb(80,0,80)">
<div class=3D"gmail-m_5827365450680548321ss-form-heading">
<h1 class=3D"gmail-m_5827365450680548321ss-form-title" dir=3D"ltr" style=3D"margin:0.67em 0px">
Registro de Atenci==C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"gmail-m_5827365450680548321ss-form-desc gmail-m_5827365450680548321ss-no-ignore-whitespace" style=3D"font:inherit;width:617.75px;margin:0px 0px 1em;white-space:pre-wrap">
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.</div>
</div>
</span>
<div class=3D"gmail-m_5827365450680548321ss-form">
<form method=3D"GET" id=3D"gmail-m_5827365450680548321ss-form">
<span class==3D"gmail-im" style=3D"color:rgb(80,0,80)">
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321emailAddress">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Email address=C2=A0<label for=3D"m_5827365450680548321emailAddress">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
</label>
<div class=3D"gmail-m_5827365450680548321ss-q-text gmail-m_5827365450680548321ss-printable-text-line" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
<a href=3D"mailto:waltermuschen@gmail.com" target=3D"_blank">
waltermuschen@gmail.com</a>
</div>
</div>
</div>
</div>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class==3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-embeddable-object-container" style=3D"margin:12px 0px;max-width:100%">
<div class==3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"margin-top:0.83em;margin-bottom:0.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"gmail-m_5827365450680548321ss-image gmail-CToWUd" title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" alt=3D"Captionless Image" style=3D"width: 78px; outline: none;">
</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-page-break" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-page-title" style=3D"padding:0.4em;background-color:rgb(238,238,238)">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"gmail-m_5827365450680548321ss-page-description gmail-m_5827365450680548321ss-no-ignore-whitespace" dir=3D"auto" style=3D"white-space:pre-wrap">
Aqu=C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_579114469">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Primer Nombre y Apellido Paterno=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
</div>
</label>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
Walter M=C3=BCschen</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-text" style==3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_1276273985">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
RUT=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class==3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir==3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
6979478-5</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-select" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_133691676">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
Si asisten m=C3=A1s de 1 prestador simult=C3=A1neamente, cada uno debe hacer un registro independiente</div>
</label>
<select name=3D"entry.133691676" disabled id=3D"gmail-m_5827365450680548321entry_133691676" style==3D"font-size:13px">
<option value=3D"">
</option>
=C2=A0<option value=3D"MEDICO" disabled selected>
MEDICO</option>
=C2=A0<option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
=C2=A0<option value=3D"TENS" disabled>
TENS</option>
=C2=A0<option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
=C2=A0<option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
=C2=A0<option value=3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-embeddable-object-container" style=3D"margin:12px 0px;max-width:100%">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"margin-top:0.83em;margin-bottom:0.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"gmail-m_5827365450680548321ss-image gmail-CToWUd" title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" alt=3D"Captionless Image" style=3D"width: 78px; outline: none;">
</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-page-break" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style==3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-page-title" style=3D"padding:0.4em;background-color:rgb(238,238,238)">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"gmail-m_5827365450680548321ss-page-description gmail-m_5827365450680548321ss-no-ignore-whitespace" dir=3D"auto" style==3D"white-space:pre-wrap">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-section-header" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-section-title" style=3D"background-color:rgb(238,238,238);padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"gmail-m_5827365450680548321ss-section-description gmail-m_5827365450680548321ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap">
</div>
</div>
</div>
</div>
<br>
</span>
<div class==3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<span class=3D"gmail-im" style=3D"color:rgb(80,0,80)">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_823811303">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Rut del Paciente=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
</span>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
9295192-8</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<span class=3D"gmail-im" style=3D"color:rgb(80,0,80)">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_1959365839">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
</div>
</label>
</span>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
Marta De la Hoz</div>
</div>
</div>
</div>
<div>
<div class=3D"gmail-adm" style=3D"margin:5px 0px">
<div id=3D"gmail-q_793" class=3D"gmail-ajR gmail-h4" style=3D"background-color:rgb(232,234,237);border:none;clear:both;line-height:6px;outline:none;width:24px;color:rgb(80,0,80);font-size:11px;border-radius:5.5px">
<div class=3D"gmail-ajT" style=3D"background:url(&quot;https://www.gstatic.com/images/icons/material/system/1x/more_horiz_black_20dp.png&quot;) 50% 50%/20px no-repeat;height:11px;opacity:0.54;width:24px">
</div>
</div>
</div>
</div>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-paragraph-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_2140974612">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Anamnesis/Evoluci=C3=B3n=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
</div>
</label>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
Paciente se ha sentido bien, a excepci=C3=B3n de ciertos malestares en ambos pulgares.  Cierta alergia en relaci=C3=B3n a los parches Transtec.  Buen apetito, buen tr=C3=A1nsito intestinal, con diarreas autolimitadas ocasionales.  Herida operatoria casi sana.  Se levanta diariamente. </div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class==3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-item-required gmail-m_5827365450680548321ss-paragraph-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_824006088">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Examen F=C3=ADsico=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
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<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
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En cama, BEG, normotensa 124/80, normoc=C3=A1rdica 77/min, normosat. de O2 99%, pulmones limpios, abdomen BDI, sin masas palpables evidentes, EII sin edemas, mu=C3=B1=C3=B3n de muslo derecho con herida operatoria cubierta por ap=C3=B3sito, que no se descubre.  </div>
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<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
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<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_1690694733">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Diagn=C3=B3stico=C2==A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
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<span class=3D"gmail-m_5827365450680548321ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
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<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style==3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
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C=C3=A1ncer de ovario</div>
</div>
</div>
</div>
<span class=3D"gmail-im" style=3D"color:rgb(80,0,80)">
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
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<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_1255665248">
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Plan de Tratamiento e Indicaciones=C2=A0<label for=3D"m_5827365450680548321itemView.getDomIdToLabel()">
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Visita semanal para manejo de s=C3=ADntomas y patolog=C3=ADas intercurrentes.</div>
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</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
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Medicamentos Indicados</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
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Se mantienen.</div>
</div>
</div>
</div>
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<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
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Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
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2026</option>
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2027</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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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>
=C2=A0<option value=3D"2064">
2064</option>
=C2=A0<option value=3D"2065">
2065</option>
=C2=A0<option value=3D"2066">
2066</option>
=C2=A0<option value=3D"2067">
2067</option>
=C2=A0<option value=3D"2068">
2068</option>
=C2=A0<option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_74766472">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tratamiento Realizado (si corresponde)</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
</div>
</label>
<div class=3D"gmail-m_5827365450680548321ss-q-text" dir=3D"auto" style=3D"background-color:rgb(238,238,238);max-width:90%;border:1px solid rgb(192,192,192);padding:5px;white-space:pre-wrap;color:rgb(84,84,84);width:436.8px">
</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321ss-form-question gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-checkbox" style=3D"margin:12px 0px">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<label class=3D"gmail-m_5827365450680548321ss-q-item-label" for=3D"m_5827365450680548321entry_1219705969">
<div class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div class=3D"gmail-m_5827365450680548321ss-q-help gmail-m_5827365450680548321ss-secondary-text" dir==3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
S=C3=B3lo llene esta secci=C3=B3n si es m=C3=A9dico y solicita la visita de otro prestador del equipo</div>
</label>
<ul class=3D"gmail-m_5827365450680548321ss-choices" style=3D"list-style:none;padding:0px;margin:0.5em 0px 0px">
<li class=3D"gmail-m_5827365450680548321ss-choice-item" style=3D"margin:0px;line-height:1.3em;padding-bottom:0.5em">
<label>
<span class=3D"gmail-m_5827365450680548321ss-choice-item-control gmail-m_5827365450680548321goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"ENFERMERA" id=3D"gmail-m_5827365450680548321group_503039759_1" class=3D"gmail-m_5827365450680548321ss-q-checkbox" style=3D"font-size:13px">
</span>
=C2=A0<span class=3D"gmail-m_5827365450680548321ss-choice-label">
ENFERMERA</span>
</label>
</li>
<li class=3D"gmail-m_5827365450680548321ss-choice-item" style=3D"margin:0px;line-height:1.3em;padding-bottom:0.5em">
<label>
<span class=3D"gmail-m_5827365450680548321ss-choice-item-control gmail-m_5827365450680548321goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"TENS" id=3D"gmail-m_5827365450680548321group_503039759_2" class=3D"gmail-m_5827365450680548321ss-q-checkbox" style=3D"font-size:13px">
</span>
==C2=A0<span class=3D"gmail-m_5827365450680548321ss-choice-label">
TENS</span>
</label>
</li>
<li class=3D"gmail-m_5827365450680548321ss-choice-item" style=3D"margin:0px;line-height:1.3em;padding-bottom:0.5em">
<label>
<span class==3D"gmail-m_5827365450680548321ss-choice-item-control gmail-m_5827365450680548321goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"NUTRICIONISTA" id=3D"gmail-m_5827365450680548321group_503039759_3" class=3D"gmail-m_5827365450680548321ss-q-checkbox" style=3D"font-size:13px">
</span>
=C2=A0<span class=3D"gmail-m_5827365450680548321ss-choice-label">
NUTRICIONISTA</span>
</label>
</li>
<li class=3D"gmail-m_5827365450680548321ss-choice-item" style=3D"margin:0px;line-height:1.3em;padding-bottom:0.5em">
<label>
<span class=3D"gmail-m_5827365450680548321ss-choice-item-control gmail-m_5827365450680548321goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled checked value=3D"KINESIOLOGO" id=3D"gmail-m_5827365450680548321group_503039759_4" class=3D"gmail-m_5827365450680548321ss-q-checkbox" style=3D"font-size:13px">
</span>
=C2=A0<span class=3D"gmail-m_5827365450680548321ss-choice-label">
KINESIOLOGO</span>
</label>
</li>
<li class=3D"gmail-m_5827365450680548321ss-choice-item" style=3D"margin:0px;line-height:1.3em;padding-bottom:0.5em">
<label>
<span class=3D"gmail-m_5827365450680548321ss-choice-item-control gmail-m_5827365450680548321goog-inline-block" style=3D"display:inline-block">
<input type=3D"checkbox" name=3D"entry.503039759" disabled value=3D"PSICOLOGO" id=3D"gmail-m_5827365450680548321group_503039759_5" class=3D"gmail-m_5827365450680548321ss-q-checkbox" style=3D"font-size:13px">
</span>
=C2=A0<span class=3D"gmail-m_5827365450680548321ss-choice-label">
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_5827365450680548321errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_5827365450680548321ss-item gmail-m_5827365450680548321ss-embeddable-object-container" style=3D"margin:12px 0px;max-width:100%">
<div class=3D"gmail-m_5827365450680548321ss-form-entry" style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0px;margin-top:0px;max-width:100%">
<h2 class=3D"gmail-m_5827365450680548321ss-q-title" style=3D"margin-top:0.83em;margin-bottom:0.83em">
</h2>
<br class=3D"gmail-Apple-interchange-newline">
</div>
</div>
</div>
</span>
</form>
</div>
</div>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
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