<br>
<br>
---------- Mensaje reenviado ----------<br>
De: <b>
Google Forms</b>
 &lt;<a href=3D"mailto:forms-receipts-noreply@google.com">
forms-receipts-noreply@google.com</a>
&gt;<br>
Fecha: jueves, 2 de mayo de 2019<br>
Asunto: Registro de Atenci=C3=B3n Domiciliaria Oncovida<br>
Para: <a href=3D"mailto:md.eury@gmail.com">
md.eury@gmail.com</a>
<br>
<br>
<br>
<div style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;margin:0;padding:0;height:100%;width:100%">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" style=3D"background-color:rgb(38,4,154)" width=3D"100%">
<tbody>
<tr height=3D"64px">
<td style==3D"padding-left:24px">
<img alt=3D"Google Forms" height=3D"26px" style=3D"display:inline-block;margin:0;vertical-align:middle" width=3D"143px" src=3D"https://www.gstatic.com/docs/forms/google_forms_logo_lockup_white_2x.png">
</td>
</tr>
</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" style==3D"background-color:#fff" width=3D"100%">
<tbody>
<tr height=3D"24px">
<td>
</td>
</tr>
<tr>
<td>
<div style=3D"font-size:13px;line-height:18px;color:#424242;font-weight:700">
Thanks for filling out <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:#424242">
Here&#39;s what we got from you:</div>
</td>
</tr>
<tr>
<td>
<div>
<div>
<h1 dir=3D"ltr" style=3D"margin:.67em 0">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div 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=C3=B3n indique su correo electr=C3=B3nico.</div>
</div>
<div>
<form method=3D"GET" target=3D"_blank">
<br>
<div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Email address<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
</label>
<div 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%">
<a href=3D"mailto:md.eury@gmail.com" target=3D"_blank">
md.eury@gmail.com</a>
</div>
</div>
</div>
</div>
<div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh4.googleusercontent.com/7WxFGV5oEKKf6rzNb0Iw8YpwJxhebvN37sfEgvirGhVlOohE3P9pNEU3e4QpKhgH1mM-c1xwGQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Prestador</h2>
<div dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
Aqu==C3=AD debe ingresar sus datos personales</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Primer Nombre y Apellido Paterno<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Eury Gonzalez</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
RUT<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div 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%">
26220712-9</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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>
<option value=3D"">
</option>
<option value=3D"MEDICO" disabled selected>
MEDICO</option>
 <option value=3D"ENFERMERA/O" disabled>
ENFERMERA/O</option>
 <option value=3D"TENS" disabled>
TENS</option>
 <option value=3D"KINESIOLOGA/O" disabled>
KINESIOLOGA/O</option>
 <option value=3D"PSICOLOGO" disabled>
PSICOLOGO</option>
 <option value==3D"NUTRICIONISTA" disabled>
NUTRICIONISTA</option>
</select>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh4.googleusercontent.com/3_W3VwwMo1GiMEhNrv87B57PDW8BccI5mhSfE6p-lSCi4ennEWvZyCNRVNh9IS3zA_JNCIBLbA" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Identificaci=C3=B3n del Paciente</h2>
<div dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos del paciente visitado</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"background-color:#eee;padding:0.4em">
Datos Personales del Paciente</h2>
<div style=3D"margin-top:0.5em;white-space:pre-wrap;word-wrap:break-word">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Rut del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
RUT con Gui=C3=B3n y D=C3=ADgito Verificador, sin puntos ( Ej: 5632200-k)</div>
</label>
<div 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%">
9100327-9</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ingrese el Primer Nombre y Apellido Paterno del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Ingrid Garcia</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Previsi=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.545002227" disabled>
<option value=3D"">
</option>
<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
 <option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
 <option value=3D"COLMENA" disabled>
COLMENA</option>
 <option value=3D"CONSALUD" disabled>
CONSALUD</option>
 <option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
 <option value=3D"DIPRECA" disabled>
DIPRECA</option>
 <option value=3D"FONASA" disabled>
FONASA</option>
 <option value=3D"FUNDACION" disabled>
FUNDACION</option>
 <option value==3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
 <option value=3D"NUEVA MASVIDA" disabled selected>
NUEVA MASVIDA</option>
 <option value=3D"VIDATRES" disabled>
VIDATRES</option>
 <option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Ciudad<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Puerto montt</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Comuna<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Puerto Montt</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh3.googleusercontent.com/a--QM0tHOY2N-ywEy9inrBWw-4f6j9Ofzul9VQSNQn1ad8mPRl1_kCJQR9ynQdP2swvENM5UdQ" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"padding:0.4em;background-color:#eee">
Registro de la Atenci=C3==B3n Domiciliaria</h2>
<div dir=3D"auto" style=3D"white-space:pre-wrap;word-wrap:break-word">
En esta secci=C3=B3n debe ingresar los datos de la atenci=C3=B3n domiciliaria</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tipo de Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<ul style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled checked value=3D"Domicilio">
</span>
<span>
Domicilio</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"radio" name=3D"entry.1222378237" disabled value=3D"Ambulatorio">
</span>
<span>
Ambulatorio</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha de la Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div>
<div 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_month" disabled>
<option value=3D"">
Month</option>
<option value=3D"1">
January</option>
 <option value=3D"2">
February</option>
 <option value=3D"3">
March</option>
 <option value=3D"4" selected>
April</option>
 <option value=3D"5">
May</option>
 <option value=3D"6">
June</option>
 <option value=3D"7">
July</option>
 <option value=3D"8">
August</option>
 <option value=3D"9">
September</option>
 <option value=3D"10">
October</option>
 <option value=3D"11">
November</option>
 <option value=3D"12">
December</option>
</select>
   <select name=3D"entry.1705849412_day" disabled>
<option value=3D"">
Day</option>
<option value=3D"1">
1</option>
 <option value=3D"2">
2</option>
 <option value=3D"3">
3</option>
 <option value=3D"4">
4</option>
 <option value=3D"5">
5</option>
 <option value=3D"6">
6</option>
 <option value=3D"7">
7</option>
 <option value=3D"8">
8</option>
 <option value=3D"9">
9</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value==3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
 <option value=3D"21">
21</option>
 <option value=3D"22">
22</option>
 <option value=3D"23">
23</option>
 <option value=3D"24">
24</option>
 <option value=3D"25">
25</option>
 <option value=3D"26">
26</option>
 <option value=3D"27">
27</option>
 <option value=3D"28">
28</option>
 <option value=3D"29">
29</option>
 <option value=3D"30" selected>
30</option>
 <option value=3D"31">
31</option>
</select>
=20<select name=3D"entry.1705849412_year" disabled>
<option value=3D"">
Year</option>
<option value=3D"1896">
1896</option>
 <option value=3D"1897">
1897</option>
 <option value=3D"1898">
1898</option>
 <option value=3D"1899">
1899</option>
 <option value=3D"1900">
1900</option>
 <option value=3D"1901">
1901</option>
 <option value=3D"1902">
1902</option>
 <option value=3D"1903">
1903</option>
 <option value=3D"1904">
1904</option>
 <option value=3D"1905">
1905</option>
 <option value=3D"1906">
1906</option>
 <option value=3D"1907">
1907</option>
 <option value=3D"1908">
1908</option>
 <option value=3D"1909">
1909</option>
 <option value=3D"1910">
1910</option>
 <option value=3D"1911">
1911</option>
 <option value=3D"1912">
1912</option>
 <option value=3D"1913">
1913</option>
 <option value=3D"1914">
1914</option>
 <option value=3D"1915">
1915</option>
 <option value=3D"1916">
1916</option>
 <option value=3D"1917">
1917</option>
 <option value=3D"1918">
1918</option>
 <option value=3D"1919">
1919</option>
 <option value=3D"1920">
1920</option>
 <option value=3D"1921">
1921</option>
 <option value=3D"1922">
1922</option>
 <option value=3D"1923">
1923</option>
 <option value==3D"1924">
1924</option>
 <option value=3D"1925">
1925</option>
 <option value==3D"1926">
1926</option>
 <option value=3D"1927">
1927</option>
 <option value==3D"1928">
1928</option>
 <option value=3D"1929">
1929</option>
 <option value==3D"1930">
1930</option>
 <option value=3D"1931">
1931</option>
 <option value==3D"1932">
1932</option>
 <option value=3D"1933">
1933</option>
 <option value==3D"1934">
1934</option>
 <option value=3D"1935">
1935</option>
 <option value==3D"1936">
1936</option>
 <option value=3D"1937">
1937</option>
 <option value==3D"1938">
1938</option>
 <option value=3D"1939">
1939</option>
 <option value==3D"1940">
1940</option>
 <option value=3D"1941">
1941</option>
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1942</option>
 <option value=3D"1943">
1943</option>
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1944</option>
 <option value=3D"1945">
1945</option>
 <option value==3D"1946">
1946</option>
 <option value=3D"1947">
1947</option>
 <option value==3D"1948">
1948</option>
 <option value=3D"1949">
1949</option>
 <option value==3D"1950">
1950</option>
 <option value=3D"1951">
1951</option>
 <option value==3D"1952">
1952</option>
 <option value=3D"1953">
1953</option>
 <option value==3D"1954">
1954</option>
 <option value=3D"1955">
1955</option>
 <option value==3D"1956">
1956</option>
 <option value=3D"1957">
1957</option>
 <option value==3D"1958">
1958</option>
 <option value=3D"1959">
1959</option>
 <option value==3D"1960">
1960</option>
 <option value=3D"1961">
1961</option>
 <option value==3D"1962">
1962</option>
 <option value=3D"1963">
1963</option>
 <option value==3D"1964">
1964</option>
 <option value=3D"1965">
1965</option>
 <option value==3D"1966">
1966</option>
 <option value=3D"1967">
1967</option>
 <option value==3D"1968">
1968</option>
 <option value=3D"1969">
1969</option>
 <option value==3D"1970">
1970</option>
 <option value=3D"1971">
1971</option>
 <option value==3D"1972">
1972</option>
 <option value=3D"1973">
1973</option>
 <option value==3D"1974">
1974</option>
 <option value=3D"1975">
1975</option>
 <option value==3D"1976">
1976</option>
 <option value=3D"1977">
1977</option>
 <option value==3D"1978">
1978</option>
 <option value=3D"1979">
1979</option>
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1980</option>
 <option value=3D"1981">
1981</option>
 <option value==3D"1982">
1982</option>
 <option value=3D"1983">
1983</option>
 <option value==3D"1984">
1984</option>
 <option value=3D"1985">
1985</option>
 <option value==3D"1986">
1986</option>
 <option value=3D"1987">
1987</option>
 <option value==3D"1988">
1988</option>
 <option value=3D"1989">
1989</option>
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1990</option>
 <option value=3D"1991">
1991</option>
 <option value==3D"1992">
1992</option>
 <option value=3D"1993">
1993</option>
 <option value==3D"1994">
1994</option>
 <option value=3D"1995">
1995</option>
 <option value==3D"1996">
1996</option>
 <option value=3D"1997">
1997</option>
 <option value==3D"1998">
1998</option>
 <option value=3D"1999">
1999</option>
 <option value==3D"2000">
2000</option>
 <option value=3D"2001">
2001</option>
 <option value==3D"2002">
2002</option>
 <option value=3D"2003">
2003</option>
 <option value==3D"2004">
2004</option>
 <option value=3D"2005">
2005</option>
 <option value==3D"2006">
2006</option>
 <option value=3D"2007">
2007</option>
 <option value==3D"2008">
2008</option>
 <option value=3D"2009">
2009</option>
 <option value==3D"2010">
2010</option>
 <option value=3D"2011">
2011</option>
 <option value==3D"2012">
2012</option>
 <option value=3D"2013">
2013</option>
 <option value==3D"2014">
2014</option>
 <option value=3D"2015">
2015</option>
 <option value==3D"2016">
2016</option>
 <option value=3D"2017">
2017</option>
 <option value==3D"2018">
2018</option>
 <option value=3D"2019" selected>
2019</option>
 <option value=3D"2020">
2020</option>
 <option value=3D"2021">
2021</option>
 <option value=3D"2022">
2022</option>
 <option value=3D"2023">
2023</option>
 <option value=3D"2024">
2024</option>
 <option value=3D"2025">
2025</option>
 <option value=3D"2026">
2026</option>
 <option value=3D"2027">
2027</option>
 <option value=3D"2028">
2028</option>
 <option value=3D"2029">
2029</option>
 <option value=3D"2030">
2030</option>
 <option value=3D"2031">
2031</option>
 <option value=3D"2032">
2032</option>
 <option value=3D"2033">
2033</option>
 <option value=3D"2034">
2034</option>
 <option value=3D"2035">
2035</option>
 <option value=3D"2036">
2036</option>
 <option value=3D"2037">
2037</option>
 <option value==3D"2038">
2038</option>
 <option value=3D"2039">
2039</option>
 <option value==3D"2040">
2040</option>
 <option value=3D"2041">
2041</option>
 <option value==3D"2042">
2042</option>
 <option value=3D"2043">
2043</option>
 <option value==3D"2044">
2044</option>
 <option value=3D"2045">
2045</option>
 <option value==3D"2046">
2046</option>
 <option value=3D"2047">
2047</option>
 <option value==3D"2048">
2048</option>
 <option value=3D"2049">
2049</option>
 <option value==3D"2050">
2050</option>
 <option value=3D"2051">
2051</option>
 <option value==3D"2052">
2052</option>
 <option value=3D"2053">
2053</option>
 <option value==3D"2054">
2054</option>
 <option value=3D"2055">
2055</option>
 <option value==3D"2056">
2056</option>
 <option value=3D"2057">
2057</option>
 <option value==3D"2058">
2058</option>
 <option value=3D"2059">
2059</option>
 <option value==3D"2060">
2060</option>
 <option value=3D"2061">
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>
</select>
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</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;font:inherit">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Hora de la Atenci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div>
<div 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">
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<option value=3D"">
Hr</option>
<option value=3D"01">
01</option>
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02</option>
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03</option>
 <option value=3D"04">
04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07" selected>
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
</select>
:<select name=3D"entry.206244955_minute" disabled>
<option value=3D"">
Min</option>
<option value=3D"00" selected>
00</option>
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01</option>
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02</option>
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03</option>
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04</option>
 <option value=3D"05">
05</option>
 <option value=3D"06">
06</option>
 <option value=3D"07">
07</option>
 <option value=3D"08">
08</option>
 <option value=3D"09">
09</option>
 <option value=3D"10">
10</option>
 <option value=3D"11">
11</option>
 <option value=3D"12">
12</option>
 <option value=3D"13">
13</option>
 <option value=3D"14">
14</option>
 <option value=3D"15">
15</option>
 <option value=3D"16">
16</option>
 <option value=3D"17">
17</option>
 <option value=3D"18">
18</option>
 <option value=3D"19">
19</option>
 <option value=3D"20">
20</option>
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21</option>
 <option value==3D"22">
22</option>
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23</option>
 <option value=3D"24">
24</option>
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25</option>
 <option value=3D"26">
26</option>
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27</option>
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28</option>
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29</option>
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30</option>
 <option value=3D"31">
31</option>
 <option value=3D"32">
32</option>
 <option value=3D"33">
33</option>
 <option value=3D"34">
34</option>
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35</option>
 <option value=3D"36">
36</option>
 <option value=3D"37">
37</option>
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38</option>
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39</option>
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40</option>
 <option value=3D"41">
41</option>
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42</option>
 <option value=3D"43">
43</option>
 <option value=3D"44">
44</option>
 <option value=3D"45">
45</option>
 <option value=3D"46">
46</option>
 <option value=3D"47">
47</option>
 <option value=3D"48">
48</option>
 <option value=3D"49">
49</option>
 <option value=3D"50">
50</option>
 <option value=3D"51">
51</option>
 <option value=3D"52">
52</option>
 <option value=3D"53">
53</option>
 <option value=3D"54">
54</option>
 <option value=3D"55">
55</option>
 <option value=3D"56">
56</option>
 <option value=3D"57">
57</option>
 <option value=3D"58">
58</option>
 <option value=3D"59">
59</option>
</select>
<select name=3D"entry.206244955_ampm" disabled>
<option value=3D"AM">
AM</option>
<option value=3D"PM" selected>
PM</option>
</select>
<div style=3D"height:32px;vertical-align:middle;display:inline-block">
</div>
</div>
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Performance Status ECOG del Paciente<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<select name=3D"entry.1747608258" disabled>
<option value=3D"">
</option>
<option value=3D"0" disabled>
0</option>
 <option value=3D"1" disabled>
1</option>
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2</option>
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3</option>
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4</option>
</select>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;overflow-x:auto">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA Actual</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0">
<tbody>
<tr>
<td style=3D"text-align:center">
</td>
<td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td style=3D"text-align:center">
</td>
</tr>
<tr>
<td style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div>
</div>
</td>
<td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"0">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"1">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled checked value=3D"2">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"3">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"4">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"5">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"6">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"7">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"8">
</div>
</td>
 <td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"9">
</div>
</td>
 <td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
<input type=3D"radio" name=3D"entry.1421689035" disabled value=3D"10">
</div>
</td>
<td style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;overflow-x:auto">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=A1ximo</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<table border=3D"0" cellpadding=3D"5" cellspacing=3D"0">
<tbody>
<tr>
<td style=3D"text-align:center">
</td>
<td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
0</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
1</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
2</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
3</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
 <td style=3D"text-align:center">
<label style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td style=3D"text-align:center">
</td>
</tr>
<tr>
<td style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div>
</div>
</td>
<td style=3D"text-align:center;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em">
<div>
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</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"1">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"2">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"3">
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<div>
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"4">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.1244707512" disabled value=3D"5">
</div>
</td>
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<div>
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</td>
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<div>
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<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Escala Dolor EVA M=C3=ADnimo</div>
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</div>
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</td>
<td style=3D"text-align:center">
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0</label>
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1</label>
</td>
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2</label>
</td>
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3</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
4</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
5</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
6</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
7</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
8</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
9</label>
</td>
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<label style=3D"display:block;padding:0.5em 0 .5em">
10</label>
</td>
<td style=3D"text-align:center">
</td>
</tr>
<tr>
<td style=3D"text-align:right;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-left:0">
<div>
</div>
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<div>
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<div>
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<div>
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"3">
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"4">
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"5">
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<div>
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<div>
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</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value==3D"8">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"9">
</div>
</td>
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<div>
<input type=3D"radio" name=3D"entry.853118630" disabled value=3D"10">
</div>
</td>
<td style=3D"text-align:left;color:#666;border:1px solid #d3d8d3;border-left:0;border-right:0;padding:.5em .25em;padding-right:0">
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Anamnesis/Evoluci=C3=B3n<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Paciente fem. 57 a=C3=B1os con dx primario de cancer de ovario. Metastasis peritoneal y pericardiogenica. Bajo peso. En esta visita refiere sentirse regular acusa episodios de distension abdominal. Cuando se excede con los carbohidratos. No ha reclamado la oxicodona por error en la escritura del codigo. </div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Examen F=C3=ADsico<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Presion arterial 114/90. Pulso 92 por minuto. Se toma circunferencia abdominal registrando 89cm. Oximetria 96%. Temperatura 35.6 grados. ORL. Normal cardiovascular sin alteraciones. Abdomen con ascitis leve con adenopatias palpables en cuadrantes superioes y endurecimiento en abdomen inferior </div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Diagn=C3=B3stico<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Ca de Ovario. Met peritoneal y pericardiofrenica.Bajo Peso</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Plan de Tratamiento e Indicaciones<label>
</label>
<span style=3D"color:#c43b1d">
*</span>
</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
Se corrige receta. Se insiste en atencion por kinesiologia y nutricion</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Medicamentos Indicados</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Fecha aproximada del Pr=C3=B3ximo Control con usted</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div>
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1920</option>
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1981</option>
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1983</option>
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1984</option>
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1985</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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1992</option>
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1993</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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2005</option>
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2006</option>
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2011</option>
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2013</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>
 <option value=3D"2063">
2063</option>
 <option value==3D"2064">
2064</option>
 <option value=3D"2065">
2065</option>
 <option value==3D"2066">
2066</option>
 <option value=3D"2067">
2067</option>
 <option value==3D"2068">
2068</option>
 <option value=3D"2069">
2069</option>
</select>
</div>
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Tratamiento Realizado (si corresponde)</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
</div>
</label>
<div 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%">
</div>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<label>
<div style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
Derivaci=C3=B3n a otro Prestador Domiciliario</div>
<div dir=3D"auto" style=3D"display:block;margin:.1em 0 .25em 0;color:#666">
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 style=3D"list-style:none;padding:0;margin:.5em 0 0">
<li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"ENFERMERA">
</span>
<span>
ENFERMERA</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"TENS">
</span>
<span>
TENS</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled checked value=3D"NUTRICIONISTA">
</span>
<span>
NUTRICIONISTA</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled checked value=3D"KINESIOLOGO">
</span>
<span>
KINESIOLOGO</span>
</label>
</li>
 <li style=3D"margin:0;line-height:1.3em;padding-bottom:.5em">
<label>
<span style=3D"display:inline-block">
<input type=3D"checkbox" name==3D"entry.503039759" disabled value=3D"PSICOLOGO">
</span>
<span>
PSICOLOGO</span>
</label>
</li>
</ul>
</div>
</div>
</div>
<br>
 <div>
<div dir=3D"auto" style=3D"margin:12px 0;max-width:100%">
<div style=3D"margin-bottom:1.5em;vertical-align:middle;margin-left:0;margin-top:0;max-width:100%">
<h2 style=3D"display:block;font-weight:bold;margin-top:.83em;margin-bottom:.83em">
</h2>
<div style=3D"text-align:right">
<img title=3D"" src=3D"https://lh6.googleusercontent.com/ho5-aEhqapElKPfY3C043hrFRDZHbYmYQL4MdTOUr9VmGAzMIk1T6XQ9jJN3CuGBWoqcxaMG3A" style=3D"width:78px;outline:none" alt=3D"Captionless Image">
</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" style=3D"max-width:672px;min-width:154px" width=3D"100%">
<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" target=3D"_blank">
Create your own Google Form</a>
</td>
</tr>
</tbody>
</table>
</div>
</div>
<br>
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