<div dir=3D"ltr">
<table border=3D"0" cellpadding=3D"0" cellspacing=3D"0" width=3D"100%" style=3D"font-family:Roboto,Helvetica,Arial,sans-serif;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"font-family:Roboto,Helvetica,Arial,sans-serif;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_7002263784265762889ss-form-container">
<div class=3D"gmail-m_7002263784265762889ss-form-heading">
<h1 class=3D"gmail-m_7002263784265762889ss-form-title" dir=3D"ltr" style=3D"margin:0.67em 0px">
Registro de Atenci=C3=B3n Domiciliaria Oncovida</h1>
<div class=3D"gmail-m_7002263784265762889ss-form-desc gmail-m_7002263784265762889ss-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>
<div class=3D"gmail-m_7002263784265762889ss-form">
<form method=3D"GET" id=3D"gmail-m_7002263784265762889ss-form">
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889emailAddress">
<div class=3D"gmail-m_7002263784265762889ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Email address=C2=A0<label for=3D"m_7002263784265762889emailAddress">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
</label>
<div class=3D"gmail-m_7002263784265762889ss-q-text gmail-m_7002263784265762889ss-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_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-embeddable-object-container" style=3D"margin:12px 0px;max-width:100%">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-title" style=3D"margin-top:0.83em;margin-bottom:0.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-page-break" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-page-title" style=3D"padding:0.4em;background-color:rgb(238,238,238)">
Identificaci=C3=B3n del Prestador</h2>
<div class=3D"gmail-m_7002263784265762889ss-page-description gmail-m_7002263784265762889ss-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_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_579114469">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-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_7002263784265762889ss-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=9Cschen</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class==3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_1276273985">
<div class=3D"gmail-m_7002263784265762889ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
RUT=C2=A0<label for=3D"m_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style==3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-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_7002263784265762889ss-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_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-select" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_133691676">
<div class=3D"gmail-m_7002263784265762889ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Tipo=C2=A0<label for=3D"m_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-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_7002263784265762889entry_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_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-embeddable-object-container" style=3D"margin:12px 0px;max-width:100%">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-title" style=3D"margin-top:0.83em;margin-bottom:0.83em">
</h2>
<div style=3D"text-align:right">
<img class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-page-break" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-page-title" style=3D"padding:0.4em;background-color:rgb(238,238,238)">
Identificaci=C3=B3n del Paciente</h2>
<div class=3D"gmail-m_7002263784265762889ss-page-description gmail-m_7002263784265762889ss-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_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-section-header" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-section-title" style=3D"background-color:rgb(238,238,238);padding:0.4em">
Datos Personales del Paciente</h2>
<div class=3D"gmail-m_7002263784265762889ss-section-description gmail-m_7002263784265762889ss-no-ignore-whitespace" style=3D"margin-top:0.5em;white-space:pre-wrap">
</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_823811303">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-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_7002263784265762889ss-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">
7880060-7</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style==3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_1959365839">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-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_7002263784265762889ss-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">
Gabriel Aedo</div>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-select" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for==3D"m_7002263784265762889entry_545002227">
<div class=3D"gmail-m_7002263784265762889ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Previsi=C3=B3n=C2=A0<label for=3D"m_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
<div class=3D"gmail-m_7002263784265762889ss-q-help gmail-m_7002263784265762889ss-secondary-text" dir=3D"auto" style=3D"margin:0.1em 0px 0.25em;color:rgb(102,102,102)">
</div>
</label>
<select name=3D"entry.545002227" disabled id=3D"gmail-m_7002263784265762889entry_545002227" style=3D"font-size:13px">
<option value=3D"">
</option>
=C2=A0<option value=3D"BANMEDICA" disabled>
BANMEDICA</option>
==C2=A0<option value=3D"CAPREDENA" disabled>
CAPREDENA</option>
=C2=A0<option value=3D"COLMENA" disabled selected>
COLMENA</option>
=C2=A0<option value=3D"CONSALUD" disabled>
CONSALUD</option>
=C2=A0<option value=3D"CRUZ BLANCA" disabled>
CRUZ BLANCA</option>
=C2=A0<option value=3D"DIPRECA" disabled>
DIPRECA</option>
=C2=A0<option value=3D"FONASA" disabled>
FONASA</option>
=C2=A0<option value=3D"FUNDACION" disabled>
FUNDACION</option>
=C2=A0<option value=3D"ISAPRES DEL COBRE" disabled>
ISAPRES DEL COBRE</option>
=C2=A0<option value=3D"NUEVA MASVIDA" disabled>
NUEVA MASVIDA</option>
=C2=A0<option value=3D"VIDATRES" disabled>
VIDATRES</option>
=C2=A0<option value=3D"PARTICULAR" disabled>
PARTICULAR</option>
</select>
</div>
</div>
</div>
<br>
<div class=3D"gmail-m_7002263784265762889ss-form-question gmail-m_7002263784265762889errorbox-good">
<div dir=3D"auto" class=3D"gmail-m_7002263784265762889ss-item gmail-m_7002263784265762889ss-item-required gmail-m_7002263784265762889ss-text" style=3D"margin:12px 0px">
<div class=3D"gmail-m_7002263784265762889ss-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_7002263784265762889ss-q-item-label" for=3D"m_7002263784265762889entry_1900161356">
<div class=3D"gmail-m_7002263784265762889ss-q-title" style=3D"font-weight:bold;margin-top:0.83em;margin-bottom:0.83em">
Ciudad=C2=A0<label for=3D"m_7002263784265762889itemView.getDomIdToLabel()">
</label>
<span class=3D"gmail-m_7002263784265762889ss-required-asterisk" style=3D"color:rgb(196,59,29)">
*</span>
</div>
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