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<p><span style="font-family:Arial Black;font-size:14pt;font-weight:600;text-decoration:underline">Bénéficiaire</span><span style="font-family:Arial;font-size:14pt">             </span><span style="font-family:Arial;font-size:14pt;font-weight:600">Le</span><span style="font-family:Arial;font-size:14pt"> {{DATE}} </span><span style="font-family:Arial;font-size:14pt;font-weight:600">à</span><span style="font-family:Arial;font-size:14pt">  {{TIME}}</span></p>
<p><span style="font-size:14pt;font-weight:600">Nom</span><span style="font-size:14pt"> : 				{{NOM PATIENT}}			<br /></span><span style="font-size:14pt;font-weight:600">Nom de naissance</span><span style="font-size:14pt"> : 		{{NOM PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Prenom</span><span style="font-size:14pt">: 			{{PRENOM PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Date de naissance</span><span style="font-size:14pt"> : 		{{DATE NAISSANCE PATIENT}}		</span><span style="font-size:14pt;font-weight:600">Sexe</span><span style="font-size:14pt"> :  {{SEXE PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Titre</span><span style="font-size:14pt"> :   			{{TITRE PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Profession </span><span style="font-size:14pt">: 			{{PROFESSION PATIENT}}<br /></span><span style="font-family:Courier New;font-size:14pt;font-weight:600">___________________ </span><span style="font-family:Courier New;font-style:italic;font-size:14pt;font-weight:600">Adresse et contact</span><span style="font-family:Courier New;font-size:14pt;font-weight:600"> _________________________</span><span style="font-size:14pt"><br /></span><span style="font-size:14pt;font-weight:600">Adresse</span><span style="font-size:14pt"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-size:14pt;font-weight:600">Ville</span><span style="font-size:14pt"> : {{VILLE PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Code postal </span><span style="font-size:14pt">: {{CODE POSTAL PATIENT}}<br /><br /></span><span style="font-size:14pt;font-weight:600">Tél 1</span><span style="font-size:14pt"> : {{NUM. TEL1 PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Tél 2</span><span style="font-size:14pt"> : {{NUM. TEL2 PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Tél 3</span><span style="font-size:14pt"> : {{NUM. TEL3 PATIENT}}<br /></span><span style="font-size:14pt;font-weight:600">Email </span><span style="font-size:14pt">: {{EMAIL PATIENT}}<br /></span><span style="font-family:Courier New;font-size:14pt;font-weight:600">___________________ </span><span style="font-family:Courier New;font-style:italic;font-size:14pt;font-weight:600">Couverture sociale</span><span style="font-family:Courier New;font-size:14pt;font-weight:600"> ___________________________</span><span style="font-size:14pt"><br /></span><span style="font-size:14pt;font-weight:600">Ayant droit en tant que</span><span style="font-size:14pt"> : 		{{QUALITE AYANT DROIT}}<br /></span><span style="font-size:14pt;font-weight:600">Numéro de sécurité sociale </span><span style="font-size:14pt">: 	{{NUM. SECU PATIENT}}    </span><span style="font-size:14pt;font-weight:600">Rang gémellaire</span><span style="font-size:14pt"> :  {{RANG GEM}}<br /></span><span style="font-size:14pt;font-weight:600">Droits  début</span><span style="font-size:14pt"> : 	{{DEBUT DROITS}}<br />              </span><span style="font-size:14pt;font-weight:600">fin</span><span style="font-size:14pt"> :		{{FIN DROITS}}<br /></span><span style="font-size:14pt;font-weight:600">Code régime</span><span style="font-size:14pt"> : {{CODE REGIME}}<br /></span><span style="font-size:14pt;font-weight:600">Caisse gestionnaire</span><span style="font-size:14pt"> : 	{{CAISSE GESTIONNAIRE}}<br /></span><span style="font-size:14pt;font-weight:600">Centre gestionnaire</span><span style="font-size:14pt"> : {{CENTRE GESTIONNAIRE}}<br /></span><span style="font-size:14pt;font-weight:600">Code gestion</span><span style="font-size:14pt"> : {{CODE GESTION}}<br /><br /><br /><hr></span><span style="font-family:Arial Black;font-size:14pt;font-weight:600;text-decoration:underline">Assuré</span></p>
<p><span style="font-size:14pt;font-weight:600">Nom assuré </span><span style="font-size:14pt">: 		{{NOM ASSURE}}<br /></span><span style="font-size:14pt;font-weight:600">Prénom assuré</span><span style="font-size:14pt"> : 	{{PRENOM ASSURE}}<br /></span><span style="font-size:14pt;font-weight:600">Date de naissance assuré </span><span style="font-size:14pt">: {{DATE NAISSANCE ASSURE}}</span></p>
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