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{\*\docvar {TPOSkgC1xmZxx9FjGzCb}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="ECG" TableTitle="ECG" NoDataText="No ECG results recorded." GUID="fb03358b-625a-4c92-bd95-f89a2973d481" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataAction=
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{\*\docvar {TpuaKHxuLeZmQ4GhoJ38}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Weight" TableTitle="Weight" NoDataText="No weights recorded." GUID="71d40ab3-b54f-44dd-bb55-e32eca6c2f63" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataActio
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{\*\docvar {Tq3VL9ASfd58991OgyBn}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="HbA1c" TableTitle="HbA1c" NoDataText="No HbA1c values recorded." GUID="f02db016-3cf5-48ea-a4a4-8d1766b65071" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataAc
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{\*\docvar {Tsx1jrZjhQJ5Z9QVRdXw}{T<ClinicalContentTableType IncludeMostRecentOnly="true" UIDisplayName="Family History" TableTitle="Family History" NoDataText="No family history recorded." GUID="b450ab8f-96d8-4b3d-9121-e6dd629f397b" DisplayTitle="true" DisplayHeaderRow="true" DisplayBord
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{\*\docvar {Ttip9vQQTtQFVen37tLw}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Smoking" TableTitle="Smoking" NoDataText="No smoking recorded." GUID="176ec944-a63e-4fa3-9ba5-47158f792ef0" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataAct
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{\*\docvar {TuIMbh38BampUTbynRfV}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Problems" TableTitle="Problems" NoDataText="No problems recorded." GUID="02800f4c-0905-42e0-849a-85215094a468" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoData
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{\*\docvar {TXFX2VVBr1duv2DyEfwe}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Smoking Status" TableTitle="Single Code Entry" NoDataText="No events found." GUID="8cd205c6-f33a-4045-a2be-42c818fc7bb4" DisplayTitle="false" DisplayHeaderRow="fals
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{\*\docvar {Tzjzy1QeioK5ZWZPYZFq}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Cervical Smear" TableTitle="Cervical Smear" NoDataText="No cervical smears found." GUID="fde5979e-be97-486e-86a0-d27bcb97899a" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorde
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{\*\docvar {TzUjKBxC6tslyvO9rYyf}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Allergies" TableTitle="Allergies" NoDataText="No allergies recorded." GUID="d428fcd5-e909-4cc7-95f2-a53aba18520a" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoD
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\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3334\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell NHS Number:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PbcrijmdEUrDin7YSLB7}{\*\bkmkstart ICG_NHSNumber}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
00020000140000001450626372696a6d6445557244696e3759534c423700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PbcrijmdEUrDin7YSLB7}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
NHS Number}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend PbcrijmdEUrDin7YSLB7}{\*\bkmkend ICG_NHSNumber}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3344\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid4072979 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid1994260 Patient Details
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 Title:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart P6wJNKmbl5awmfLRKvp5}{\*\bkmkstart ICG_PreNominal}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
0002000014000000145036774a4e4b6d626c3561776d664c524b76703500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P6wJNKmbl5awmfLRKvp5}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Title}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend P6wJNKmbl5awmfLRKvp5}{\*\bkmkend ICG_PreNominal}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Forename(s):
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart P4uxHc2g2nb8DkR2NphF}{\*\bkmkstart ICG_Forenames}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
0002000014000000145034757848633267326e6238446b52324e70684600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P4uxHc2g2nb8DkR2NphF}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Given Name}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend P4uxHc2g2nb8DkR2NphF}{\*\bkmkend ICG_Forenames}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Surname:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PXf47eO9MsPlyDfHbG3m}{\*\bkmkstart ICG_Surname}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
0002000014000000145058663437654f394d73506c794466486247336d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PXf47eO9MsPlyDfHbG3m}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Surname}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend PXf47eO9MsPlyDfHbG3m}{\*\bkmkend ICG_Surname}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 Date of Birth:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PlcEx5VO26wT314Y1fKQ}{\*\bkmkstart ICG_DateOfBirth}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FOR}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 MTEXT }{\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 000200001400000014506c63457835564f323677543331345931664b5100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlcEx5VO26wT314Y1fKQ}}}}}{\fldrslt {
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 Date of Birth}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 {\*\bkmkend PlcEx5VO26wT314Y1fKQ}{\*\bkmkend ICG_DateOfBirth}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Gender:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PbKGKfdSDh7y4xy7ZCUc}{\*\bkmkstart ICG_Gender}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
00020000140000001450624b474b66645344683779347879375a43556300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PbKGKfdSDh7y4xy7ZCUc}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Gender}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend PbKGKfdSDh7y4xy7ZCUc}{\*\bkmkend ICG_Gender}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Ethnicity:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PpdlanhC4tuNEj5r2i2H}{\*\bkmkstart ICG_Ethnicity}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
0002000014000000145070646c616e68433474754e456a35723269324800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PpdlanhC4tuNEj5r2i2H}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Ethnic Origin}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend PpdlanhC4tuNEj5r2i2H}
{\*\bkmkend ICG_Ethnicity}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid1994260 Contact Details
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 Address Line 1:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart Pd1b2H15njjHltjhGqBs}{\*\bkmkstart ICG_Address1}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 00020000140000001450643162324831356e6a6a486c746a684771427300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pd1b2H15njjHltjhGqBs}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address House Name/Flat Number}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid12401825 {\*\bkmkend Pd1b2H15njjHltjhGqBs}{\*\bkmkend ICG_Address1}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell Address Line 2
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PLj9JPdbWLvJ9iYi6mZ5}{\*\bkmkstart ICG_Address2}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 000200001400000014504c6a394a506462574c764a39695969366d5a3500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PLj9JPdbWLvJ9iYi6mZ5}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address Number and Street}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend PLj9JPdbWLvJ9iYi6mZ5}{\*\bkmkend ICG_Address2}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell Address Line 3:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PdW8ctheFPqnCVBwdi2y}{\*\bkmkstart ICG_Address3}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 00020000140000001450645738637468654650716e435642776469327900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PdW8ctheFPqnCVBwdi2y}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address Village}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend PdW8ctheFPqnCVBwdi2y}{\*\bkmkend ICG_Address3}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 Town:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart P59xciERI4YDjggyc2xu}{\*\bkmkstart ICG_Town}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 0002000014000000145035397863694552493459446a6767796332787500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P59xciERI4YDjggyc2xu}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address Town}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend P59xciERI4YDjggyc2xu}{\*\bkmkend ICG_Town}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell County:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart P45h3T5rs8fceXW19ltc}{\*\bkmkstart ICG_County}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 00020000140000001450343568335435727338666365585731396c746300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P45h3T5rs8fceXW19ltc}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address County}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend P45h3T5rs8fceXW19ltc}{\*\bkmkend ICG_County}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell Postcode:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart P9DJ9K25zvod6YSbo6fj}{\*\bkmkstart ICG_Postcode}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 0002000014000000145039444a394b32357a766f64365953626f36666a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P9DJ9K25zvod6YSbo6fj}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Home Address Postcode}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend P9DJ9K25zvod6YSbo6fj}{\*\bkmkend ICG_Postcode}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 
\af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 Phone:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PlLoDcWZyDihSXBAoNcM}{\*\bkmkstart ICG_Phone}{\*\bkmkstart OLE_LINK8}{\*\bkmkstart OLE_LINK9}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 {\*\datafield 000200001400000014506c4c6f4463575a79446968535842416f4e634d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlLoDcWZyDihSXBAoNcM}}}}}{\fldrslt {
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 Patient Home Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid12401825 {\*\bkmkend PlLoDcWZyDihSXBAoNcM}{\*\bkmkend ICG_Phone}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 {\*\bkmkend OLE_LINK8}{\*\bkmkend OLE_LINK9}\cell Mobile:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart PlzRvHxUUdOFHZJ5KzIS}{\*\bkmkstart ICG_Mobile}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid12401825 
{\*\datafield 000200001400000014506c7a527648785555644f46485a4a354b7a495300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlzRvHxUUdOFHZJ5KzIS}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid5918963\charrsid12401825 Patient Mobile Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 
{\*\bkmkend PlzRvHxUUdOFHZJ5KzIS}{\*\bkmkend ICG_Mobile}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 Text Message Consent:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid10642810\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart ICG_TextMessageConsent}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825  FORMDROPDOWN }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 {\*\datafield 
668000000000000000000000000000000000000000000b000200020000000a0004000700024e6f03596573}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffdefres0{\*\ffl No}{\*\ffl Yes}}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 {\*\bkmkend ICG_TextMessageConsent}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10043812\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 
\af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 Email:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid14767750\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_EmailAddress}
{\*\bkmkstart PPilrNTVfFC3NAjcu7p9}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 {\*\datafield 
0002000014000000145050696c724e5456664643334e416a637537703900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PPilrNTVfFC3NAjcu7p9}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 
Patient E-mail Address}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 {\*\bkmkend ICG_EmailAddress}
{\*\bkmkend PPilrNTVfFC3NAjcu7p9} \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9403445\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 \cell \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9403445\charrsid7167928 
\trowd \irow3\irowband3\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid1994260 Referrer/Practice Details
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 Referring Name:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart RrZxOjuO5IG4tLHRtRWw}{\*\bkmkstart ICG_ReferrerName}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5142252\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5142252\charrsid7548891 {\*\datafield 
00020000140000001452725a784f6a754f35494734744c48527452577700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RrZxOjuO5IG4tLHRtRWw}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5142252\charrsid7548891 
Referring User}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend RrZxOjuO5IG4tLHRtRWw}
{\*\bkmkend ICG_ReferrerName}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3338\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Referrer Code:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart FAFlGDWJbciE4LCfPXsj}{\*\bkmkstart ICG_ReferrerCode}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid7548891 {\*\datafield 
0002000014000000144641466c4744574a62636945344c43665058736a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname FAFlGDWJbciE4LCfPXsj}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid357474\charrsid7548891 
Free Text Prompt}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid7548891 {\*\bkmkend FAFlGDWJbciE4LCfPXsj}{\*\bkmkend ICG_ReferrerCode} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3330\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell Practice Code:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart OzgrO1hLjVDbpOxgDiJ2}{\*\bkmkstart ICG_Practice}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid7548891 {\*\datafield 
0002000014000000144f7a67724f31684c6a564462704f786744694a3200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname OzgrO1hLjVDbpOxgDiJ2}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid7548891 
Organisation National Practice Code}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend OzgrO1hLjVDbpOxgDiJ2}
{\*\bkmkend ICG_Practice}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3352\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid1994260 Clinic Details
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx3462\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx7012\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 Specialty:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_Specialty}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid11167494\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid11167494\charrsid7548891 {\*\datafield 
00000000000000000d4943475f5370656369616c747900033257570000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_Specialty}{\*\ffdeftext 2WW}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid11167494\charrsid7548891 2WW}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 
{\*\bkmkend ICG_Specialty}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3349\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx3462\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx7012\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 \cell Clinic Type:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_ClinicType}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118\charrsid7548891 {\*\datafield 
00000000000000000e4943475f436c696e6963547970650011325757204865616420616e64204e65636b0000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_ClinicType}{\*\ffdeftext 2WW Head and Neck}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid8469118\charrsid7548891 2WW Head and Neck}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 {\*\bkmkend ICG_ClinicType}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx3462\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx7012\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 \cell Named Clinician:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_NamedClinician
}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid7548891  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid7548891 {\*\datafield 
0000000000000000124943475f4e616d6564436c696e696369616e00000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_NamedClinician}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid7548891 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid3228556\charrsid7548891 {\*\bkmkend ICG_NamedClinician}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7548891 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx3462\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx7012\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid7548891 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 \trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx3462\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx7012\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw20 \cellx10575\row 
}\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 Patient Choice Preferences}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid1994260 
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw20 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid1994260 Provider 1:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_Provider1}
{\*\bkmkstart RMbLAIPnGvVTKPRQIPj6}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10780237\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10780237\charrsid1994260 {\*\datafield 
000200001400000014524d624c4149506e477656544b50525149506a3600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RMbLAIPnGvVTKPRQIPj6}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10780237\charrsid1994260 
Referral Target Service Name}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10780237\charrsid1994260 {\*\bkmkend ICG_Provider1}
{\*\bkmkend RMbLAIPnGvVTKPRQIPj6} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid1994260 \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7167928 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx5121\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw20 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \insrsid3228556\charrsid7167928 \cell }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid352796\charrsid1994260 Provider 2}{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid3228556\charrsid1994260 :
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_Provider2}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid1994260 {\*\datafield 00000000000000000d4943475f50726f76696465723200000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_Provider2}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid1994260 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid1994260 {\*\bkmkend ICG_Provider2}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3228556\charrsid7167928 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx5120\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw20 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid7167928\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \insrsid3228556\charrsid7167928 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid7167928 
\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw20 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 
\rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9384172\charrsid1994260 Preferences
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 Vulnerable Patient:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_Vulnerable}
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825  FORMDROPDOWN }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\datafield 
66800000000000000e4943475f56756c6e657261626c65000000000000000000000000000b000200020000000a0004000700024e6f03596573}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox{\*\ffname ICG_Vulnerable}\ffdefres0{\*\ffl No}{\*\ffl Yes}}}}}{\fldrslt }}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\bkmkend ICG_Vulnerable}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9384172\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell Vulnerable Reason:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart ICG_VulnerableReason}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3478906\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3478906\charrsid12401825 {\*\datafield 
000000001400000005546578743100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid12401825 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\bkmkend ICG_VulnerableReason}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9384172\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid12401825 Confidential/}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid10043812\charrsid12401825 Silent Referral}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid15753147\charrsid12401825 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6440260\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_SilentReferral
}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825  FORMDROPDOWN }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 {\*\datafield 
6680000000000000124943475f53696c656e74526566657272616c000000000000000000000000000b000200020000000a0004000700024e6f03596573}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox{\*\ffname ICG_SilentReferral}\ffdefres0{\*\ffl No}{\*\ffl Yes}}}}
}{\fldrslt }}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 {\*\bkmkend ICG_SilentReferral}
\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10043812\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9384172\charrsid7167928 
\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 Preferred Contact Time:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart ICG_PreferredContactTime}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3478906\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3478906\charrsid12401825 {\*\datafield 
00000000000000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid12401825 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\bkmkend ICG_PreferredContactTime}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9384172\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell Interpreter Required:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart ICG_InterpreterRequired}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825  FORMDROPDOWN }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\datafield 
668000000000000000000000000000000000000000000b000200020000000a0004000700024e6f03596573}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffdefres0{\*\ffl No}{\*\ffl Yes}}}}}{\fldrslt }}\sectd \ltrsect
\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 {\*\bkmkend ICG_InterpreterRequired}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9384172\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell Preferred Language:
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart ICG_PreferredLanguage}{\*\bkmkstart PUBSQBUZIvseq43GlgvI}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid9384172\charrsid12401825 {\*\datafield 000200001400000014505542535142555a49767365713433476c67764900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PUBSQBUZIvseq43GlgvI}}}}}{\fldrslt {\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 Main Language}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid9384172\charrsid12401825 {\*\bkmkend ICG_PreferredLanguage}{\*\bkmkend PUBSQBUZIvseq43GlgvI} \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid9384172\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6235651\yts18 \rtlch\fcs1 \af0\afs20\alang1025 
\ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9384172\charrsid7167928 
\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw20 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid8791918\charrsid1994260 \page }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 Referral Details
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid11025966\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid6322439\charrsid12401825 Non-clinical information for the booking team:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid12401825 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid11025966\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_AdminNotes}
{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5579212\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5579212\charrsid12401825 {\*\datafield 
00000000000000000e4943475f41646d696e4e6f74657300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_AdminNotes}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid5579212\charrsid12401825 \u8194
\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid12401825 
{\*\bkmkend ICG_AdminNotes}\nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid6322439\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid11025966\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid6322439\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6322439\charrsid7167928 \trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6514543\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid16334377\charrsid12401825 Provisional Diagnosis:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6514543\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\field\flddirty{\*\fldinst {
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 {\*\datafield 
0000000000000000124943475f526566657272616c526561736f6e00000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_ReferralReason}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid16334377\charrsid12401825 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid16334377\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16334377\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6514543\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid16334377\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid16334377\charrsid7167928 \trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\row \ltrrow}\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid16334377\charrsid12401825 {\*\bkmkstart OLE_LINK1}{\*\bkmkstart OLE_LINK2}Smoking Status}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7210665\charrsid12401825 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 

\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid6440260\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\*\bkmkstart ICG_SmokerCode}
{\*\bkmkstart TXFX2VVBr1duv2DyEfwe}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825  FORMTEXT }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 {\*\datafield 
000200001400000014545846583256564272316475763244794566776500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TXFX2VVBr1duv2DyEfwe}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 
Single Code Entry: Smoking Status}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid12401825 {\*\bkmkend ICG_SmokerCode}
{\*\bkmkend TXFX2VVBr1duv2DyEfwe}  }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid12401825 \nestcell{\nonesttables
\par }}\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10043812\charrsid12401825 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 
\trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat19\cltxlrtb\clftsWidth1\clcbpatraw19 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\pard\plain \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid6440260\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 
\fs22\insrsid10043812\charrsid12401825 \cell }\pard\plain \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid7167928 \trowd \irow2\irowband2\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh
\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb
\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10043812\charrsid1994260 {\*\bkmkend OLE_LINK1}{\*\bkmkend OLE_LINK2}Referral }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15753147\charrsid1994260 Reason/}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 Letter}{\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid15753147\charrsid1994260  Text}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 {\*\bkmkstart ICG_ReferralNotes_S}{\*\bkmkend ICG_ReferralNotes_S}\sect }\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10043812\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10043812 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid10043812\charrsid1994260 
\par 
\par 
\par 
\par 
\par 
\par \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10043812\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7210665 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid7210665\charrsid1994260 {\*\bkmkstart ICG_ReferralNotes_E}{\*\bkmkstart ICG_ClinicalData}{\*\bkmkend ICG_ReferralNotes_E}{\*\bkmkend ICG_ClinicalData}\sect }\sectd \ltrsect
\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj \pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid4072979 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid4072979 Patient Awareness}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 Confirm that your p}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 atient understands that they have been referred onto a \'93
suspected}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 cancer pathway}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 \'94:}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 
\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid12847513 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979  FORMDROPDOWN }{\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid4072979 {\*\datafield 6680000014000000000000000000000000000000000015000300030000000a0006000e00120007556e6b6e6f776e03596573024e6f}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffhps20\ffdefres0{\*\ffl Unknown}{\*\ffl Yes}
{\*\ffl No}}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid12847513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx1807\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979 Confirm that your p}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 atient has received the }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12401825 HYPERLINK 
"http://www.valeofyorkccg.nhs.uk/rss/data/uploads/2ww-forms/patient-leaflet-2ww-final.pdf"}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12401825 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90bca00000068007400740070003a002f002f007700770077002e00760061006c0065006f00660079006f0072006b006300630067002e006e00680073002e0075006b002f007200730073002f0064006100740061002f00
750070006c006f006100640073002f003200770077002d0066006f0072006d0073002f00700061007400690065006e0074002d006c006500610066006c00650074002d003200770077002d00660069006e0061006c002e007000640066000000795881f43b1d7f48af2c825dc485276300000000a5ab0000}}}{\fldrslt {
\rtlch\fcs1 \af37 \ltrch\fcs0 \cs24\ul\cf17\insrsid4072979\charrsid2840913 information leaflet}}}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979 :}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid12847513 {\*\bkmkstart OLE_LINK16}
{\*\bkmkstart OLE_LINK17}{\*\bkmkstart OLE_LINK18}{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 {\*\datafield 
6680000014000000000000000000000000000000000015000300030000000a0006000e00120007556e6b6e6f776e03596573024e6f}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffhps20\ffdefres0{\*\ffl Unknown}{\*\ffl Yes}{\*\ffl No}}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\bkmkend OLE_LINK16}{\*\bkmkend OLE_LINK17}{\*\bkmkend OLE_LINK18}
\nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid12847513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx1807\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \trowd \irow1\irowband1\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid4072979 Confirm that your p}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 atient is available to attend an appointment within 2 weeks of this}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979  }{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid4072979\charrsid3085285 referral}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 :}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid12847513 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 
{\*\datafield 6680000014000000000000000000000000000000000015000300030000000a0006000e00120007556e6b6e6f776e03596573024e6f}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffhps20\ffdefres0{\*\ffl Unknown}{\*\ffl Yes}{\*\ffl No}}}}}{\fldrslt }}
\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid12847513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx1807\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \trowd \irow2\irowband2\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw20 \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw20 \cellx10575\row \ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 If}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 , after discussion, your patient chooses to }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid16675900 not}{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\insrsid4072979\charrsid3085285  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid3085285 attend within 2 weeks, when will they be available}{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 :
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid12847513 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid4072979 \u8194\'20\u8194\'20\u8194\'20
\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid12847513\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw20 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf18 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9918226\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrtbl \clcbpat20\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw20 \cellx10575\row }\pard\plain \ltrpar
\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid8469118 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118 Risk Factors }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs16\insrsid8469118 (tick appropriate boxes)}{\rtlch\fcs1 \af0 \ltrch\fcs0 
\fs16\insrsid8469118 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\tx2127\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8469118 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118\charrsid8469118 Smoking}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13180755 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 
{\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 
\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid8469118 Tobacco Use}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13180755 
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 
\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8469118 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid8469118\charrsid8469118 Heavy Alcohol Intake}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13180755 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 
{\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 
\trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid16149867 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid16149867 Condition Details }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b0\fs16\insrsid16149867 (tick appropriate boxes)}{\rtlch\fcs1 \af0 \ltrch\fcs0 \fs16\insrsid16149867 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13251205\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\tx2127\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8469118 \rtlch\fcs1 \af0\afs22\alang1025 
\ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118 Unexplained }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8469118 ulceration in oral cavity}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118  or 
}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8469118 vermillion of lip}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118  for >3 weeks}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid13251205 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867 {\*\datafield 
65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid16149867 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid16149867 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrs\brdrw10\brdrcf18 \clbrdrb
\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13251205\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867 \cell 
}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid16149867 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13251205\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone 
\clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4465294\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8469118 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid8469118 Unexplained }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8469118 swelling/ lump in oral cavity }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118 or}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8469118  vermillion of lip}{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid16149867 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867  FORMCHECKBOX }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16149867 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid16149867 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrs\brdrw10\brdrcf18 \clbrdrb
\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4465294\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid16149867 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid16149867 
\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4465294\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \b\insrsid8469118 Red or red and white patches}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118  of oral mucosa}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118\charrsid13251205 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13180755 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 
{\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 
\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid8469118 Unexplained and persistent }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid8469118 lump / mass in neck}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8469118  (not thyroid)}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118\charrsid13251205 
\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13180755 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118  FORMCHECKBOX }{\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid8469118 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid8469118 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf18 \trbrdrl\brdrs\brdrw10\brdrcf18 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrr\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 \trbrdrv\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl
\brdrs\brdrw10\brdrcf18 \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrs\brdrw10\brdrcf18 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid13180755 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid8469118 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid8469118 
\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf18 \trbrdrh\brdrs\brdrw10\brdrcf18 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid13180755\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 \clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw20 \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf18 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf18 
\clbrdrr\brdrnone \clcbpat20\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw20\clhidemark \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sb240\sa60\sl276\slmult1\widctlpar\brdrb\brdrs\brdrw15\brsp20 
\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7210665 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10840098\charrsid1994260 \sect }\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj \pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 
\wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8411390 Patient Readcoded Values
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid12138043\charrsid1994260 {\*\bkmkstart T3KrqOhuscI2fGRF7Dvt}EHIC: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 
{\*\datafield 00020000140000001454334b72714f687573634932664752463744767400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T3KrqOhuscI2fGRF7Dvt}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 
Single Code Entry: European health insurance card (EHIC) held}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8411390\charrsid1994260 {\*\bkmkend T3KrqOhuscI2fGRF7Dvt}  \line }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12138043\charrsid1994260 {\*\bkmkstart TOxewwtuwoHmdpdnX2DH}Smoking Status: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8411390\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 {\*\datafield 000200001400000014544f786577777475776f486d6470646e5832444800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname TOxewwtuwoHmdpdnX2DH}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 Single Code Entry: Smoking Status}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 {\*\bkmkend TOxewwtuwoHmdpdnX2DH}  \line }{\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12138043\charrsid1994260 {\*\bkmkstart TNwoTK1gbsondiKIoIX8}Religion: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 
{\*\datafield 000200001400000014544e776f544b316762736f6e64694b496f49583800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TNwoTK1gbsondiKIoIX8}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 
Single Code Entry: Religion}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260 
{\*\bkmkend TNwoTK1gbsondiKIoIX8}  
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9714368\charrsid1994260 Active Problems
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7167928 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart Tsx1jrZjhQJ5Z9QVRdXw}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\datafield 
000200001400000014547378316a725a6a68514a355a3951565264587700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tsx1jrZjhQJ5Z9QVRdXw}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 
Family History}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\bkmkend Tsx1jrZjhQJ5Z9QVRdXw
}
\par {\*\bkmkstart TuIMbh38BampUTbynRfV}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\datafield 
0002000014000000145475494d6268333842616d70555462796e52665600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TuIMbh38BampUTbynRfV}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 Problems}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\bkmkend TuIMbh38BampUTbynRfV}
\par {\*\bkmkstart TBOcKaOxzfIilhg8bQyb}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid1994260 {\*\datafield 
00020000140000001454424f634b614f787a6649696c6867386251796200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TBOcKaOxzfIilhg8bQyb}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid1994260 
Values and Investigations}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid1994260 
{\*\bkmkend TBOcKaOxzfIilhg8bQyb} 
\par {\*\bkmkstart TzUjKBxC6tslyvO9rYyf}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\datafield 
000200001400000014547a556a4b4278433674736c79764f397259796600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TzUjKBxC6tslyvO9rYyf}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 Allergies}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\bkmkend TzUjKBxC6tslyvO9rYyf}
\par {\*\bkmkstart Tji2Cbm4xf8S6h9XcaUc}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014546a693243626d3478663853366839586361556300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tji2Cbm4xf8S6h9XcaUc}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 
Alcohol Consumption}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 
{\*\bkmkend Tji2Cbm4xf8S6h9XcaUc}
\par {\*\bkmkstart Ttip9vQQTtQFVen37tLw}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
00020000140000001454746970397651515474514656656e3337744c7700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Ttip9vQQTtQFVen37tLw}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Smoking}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend Ttip9vQQTtQFVen37tLw}
\par {\*\bkmkstart TpuaKHxuLeZmQ4GhoJ38}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014547075614b4878754c655a6d513447686f4a333800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TpuaKHxuLeZmQ4GhoJ38}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Weight}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend TpuaKHxuLeZmQ4GhoJ38}
\par {\*\bkmkstart TbPLoSEeYMw1K8u9e1f5}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7241220\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7241220\charrsid1994260 {\*\datafield 
0002000014000000145462504c6f534565594d77314b3875396531663500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TbPLoSEeYMw1K8u9e1f5}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7241220\charrsid1994260 Height}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7241220\charrsid1994260 {\*\bkmkend TbPLoSEeYMw1K8u9e1f5} 
\par {\*\bkmkstart TaXAnsFWIPVlrpLoEI8J}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014546158416e7346574950566c72704c6f4549384a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TaXAnsFWIPVlrpLoEI8J}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 
Blood Pressure}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 
{\*\bkmkend TaXAnsFWIPVlrpLoEI8J}
\par {\*\bkmkstart T1XDhFibkKKcdZT6hbQs}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
00020000140000001454315844684669626b4b4b63645a54366862517300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T1XDhFibkKKcdZT6hbQs}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 BMI}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend T1XDhFibkKKcdZT6hbQs}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Medication
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7167928 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TkKfSjIKDItl8fmzwf7A}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014546b4b66536a494b4449746c38666d7a7766374100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TkKfSjIKDItl8fmzwf7A}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Medication}
}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend TkKfSjIKDItl8fmzwf7A}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Lab Results
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7167928 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TCDc1bVbRtcsaHPHNaAe}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014544344633162566252746373614850484e61416500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TCDc1bVbRtcsaHPHNaAe}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Radiology}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend TCDc1bVbRtcsaHPHNaAe}
\par {\*\bkmkstart Tq3VL9ASfd58991OgyBn}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014547133564c394153666435383939314f6779426e00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tq3VL9ASfd58991OgyBn}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 HbA1c}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend Tq3VL9ASfd58991OgyBn}
\par {\*\bkmkstart Th4psVmOW75BsMNMHkwH}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
0002000014000000145468347073566d4f57373542734d4e4d486b774800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Th4psVmOW75BsMNMHkwH}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Urinalysis}
}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend Th4psVmOW75BsMNMHkwH}
\par {\*\bkmkstart TiEhsAhee4vB8qDVgtki}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\datafield 
0002000014000000145469456873416865653476423871445667746b6900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TiEhsAhee4vB8qDVgtki}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 Haematology}
}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\bkmkend TiEhsAhee4vB8qDVgtki}
\par {\*\bkmkstart TLw1x4vAa8madiIjMDRm}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\datafield 
000200001400000014544c77317834764161386d616469496a4d44526d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TLw1x4vAa8madiIjMDRm}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 Lipids}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid1994260 {\*\bkmkend TLw1x4vAa8madiIjMDRm}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Diagnostics
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7167928 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TPOSkgC1xmZxx9FjGzCb}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
00020000140000001454504f536b674331786d5a787839466a477a436200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TPOSkgC1xmZxx9FjGzCb}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 ECG}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend TPOSkgC1xmZxx9FjGzCb}
\par {\*\bkmkstart TKc8qZZLzofqMMBuDUNP}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014544b6338715a5a4c7a6f66714d4d427544554e5000000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TKc8qZZLzofqMMBuDUNP}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 Peak Flow}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\bkmkend TKc8qZZLzofqMMBuDUNP}
\par {\*\bkmkstart Tzjzy1QeioK5ZWZPYZFq}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 {\*\datafield 
000200001400000014547a6a7a79315165696f4b355a575a50595a467100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tzjzy1QeioK5ZWZPYZFq}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840\charrsid1994260 
Cervical Smear}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15091114\charrsid1994260 
{\*\bkmkend Tzjzy1QeioK5ZWZPYZFq}
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a

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