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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
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<p><span style="font-family:MS Shell Dlg;font-weight:600">Nom</span><span style="font-family:MS Shell Dlg"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&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"> :   {{NOM PATIENT}}         &nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Prénom</span><span style="font-family:MS Shell Dlg"> : {{PRENOM PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Né</span><span style="font-family:MS Shell Dlg"> : {{DATE NAISSANCE PATIENT}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">âge</span><span style="font-family:MS Shell Dlg"> : {{AGE PATIENT ABREGE}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Adresse</span><span style="font-family:MS Shell Dlg"> :  {{ADRESSE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Code&nbsp;Postal</span><span style="font-family:MS Shell Dlg"> :  {{CODE&nbsp;POSTAL PATIENT}} </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Ville</span><span style="font-family:MS Shell Dlg"> :  {{VILLE PATIENT}} <br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Num SS</span><span style="font-family:MS Shell Dlg"> :  {{NUM. SECU PATIENT}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Assuré&nbsp;par</span><span style="font-family:MS Shell Dlg">&nbsp;: {{NOM PRENOM ASSURE}}<br /></span><span style="font-family:MS Shell Dlg;font-weight:600">Date Hospitalisation </span><span style="font-family:MS Shell Dlg">:  {{DATE VISITE}}  </span>&nbsp;<span style="font-family:MS Shell Dlg;font-weight:600">Heure&nbsp;</span><span style="font-family:MS Shell Dlg">:&nbsp;{{HHHMM}}&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">:  {{NUM. TEL1 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;2&nbsp;</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL2 PATIENT}}&nbsp;</span><span style="font-family:MS Shell Dlg;font-weight:600">Tél&nbsp;3</span><span style="font-family:MS Shell Dlg">:  {{NUM. TEL3 PATIENT}}&nbsp;<br /></span></p></td></tr>
</table>
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