<html><head><meta name="qrichtext" content="charset=utf-8" /></head><body style="font-size:9pt;font-family:Courier">
<p>{{\
{{:: SET_VAR(nom,{{NOM PATIENT}})}}\
{{:: SET_VAR(prenom,{{PRENOM PATIENT}})}}\
{{:: SET_VAR(naiss,{{DATE NAISSANCE PATIENT}})}}\
{{:: SET_VAR(age,{{AGE PATIENT ABREGE}})}}\
{{:: SET_VAR(adresse,{{ADRESSE PATIENT}})}}\
{{:: SET_VAR(codepost,{{CODE POSTAL PATIENT}})}}\
{{:: SET_VAR(ville,{{VILLE PATIENT}})}}\
{{:: SET_VAR(secu,{{NUM. SECU PATIENT}})}}\
{{:: SET_VAR(assure,{{NOM PRENOM ASSURE}})}}\
{{:: SET_VAR(date,{{DATE VISITE}})}}\
{{:: SET_VAR(heure,{{HHHMM}})}}\
{{:: SET_VAR(tel1,{{NUM. TEL1 PATIENT}})}}\
{{:: SET_VAR(tel2,{{NUM. TEL2 PATIENT}})}}\
{{:: SET_VAR(tel3,{{NUM. TEL3 PATIENT}})}}\
}}
<table border=1 cellpadding=0 cellspacing=2 width=100% >
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}        &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
<tr><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td><td width=50%>
<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{VAR=nom}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{VAR=prenom}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{VAR=naiss}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{VAR=age}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{VAR=adresse}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{VAR=codepost}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VAR=ville}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{VAR=secu}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{PUT_VAR=assure}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{VAR=date}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{:: PUT_VAR(heure)}}&nbsp;<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;1&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel1}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel2}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{VAR=tel3}}&nbsp;<br /></span></p></td></tr>
</table>
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