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<p align="center">      <span style="font-family:Arial Narrow;font-size:17pt;font-weight:600;text-decoration:underline">CLINIQUE PAS GÉNÉRALE DE SANTÉ</span><span style="font-family:Arial Narrow"><br /></span>Service des Urgences<span style="font-family:Arial Narrow;font-style:italic;font-weight:600;color:#ff0000"><br /></span><span style="font-size:7pt">(   Tél :  04 44 44 44 55   Fax:   04 44 77 88 99  )</span></p>
<p><hr><span style="font-weight:600">Nom</span>      : {{NOM PRENOM PATIENT}}        <span style="font-weight:600">Sexe</span>:{{SEXE PATIENT}}<br /><span style="font-weight:600">Né(e)</span>    : {{DATE NAISSANCE PATIENT}}            <span style="font-weight:600">Age  </span>: {{AGE PATIENT ABREGE}}<br /><span style="font-weight:600">Adresse</span>: {{ADRESSE PATIENT UNE LIGNE}}<br /><span style="font-weight:600">Tél</span>       {{NUM. TEL1 PATIENT}}                  <span style="font-weight:600">Tél 2</span>    {{NUM. TEL2 PATIENT}}<br /><hr><span style="font-weight:600">N°S.S.</span>   {{NUM. SECU PATIENT}}           <span style="font-weight:600">Vu par: </span>{{NOM PRENOM MEDECIN}}   <br /><span style="font-weight:600">Caisse S.S.             <br /></span><hr><span style="font-weight:600">Lien de parenté du patient avec l'assuré(e):    </span><span style="font-family:Arial Narrow;font-weight:600">..............................</span><span style="font-weight:600"><br />Nom et Prénom Assuré(e): </span>{{NOM PRENOM ASSURE}}<span style="font-weight:600"><br />MEDECIN TRAITANT</span>:  {{NOM PRENOM INTERVENANT=Médecine Générale}}<br /><hr></p>
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