<EMISWebDocTemplate><DisplayGroups></DisplayGroups><DefaultDocumentType></DefaultDocumentType><DocumentTypeCodeSystem></DocumentTypeCodeSystem><Description>ICG Referral Template</Description><TemplateRtf><![CDATA[{\rtf1\adeflang1025\ansi\ansicpg1252\uc1\adeff0\deff0\stshfdbch0\stshfloch37\stshfhich37\stshfbi37\deflang2057\deflangfe2057\themelang2057\themelangfe0\themelangcs0{\fonttbl{\f0\fbidi \froman\fcharset0\fprq2{\*\panose 02020603050405020304}Times New Roman;}{\f1\fbidi \fswiss\fcharset0\fprq2{\*\panose 020b0604020202020204}Arial;}
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{\f51\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\f52\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\f54\fbidi \fswiss\fcharset238\fprq2 Arial CE;}{\f55\fbidi \fswiss\fcharset204\fprq2 Arial Cyr;}
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{\fbimajor\f31539\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fbimajor\f31541\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbimajor\f31542\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}
{\fbimajor\f31543\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fbimajor\f31544\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbimajor\f31545\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}
{\fbimajor\f31546\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\flominor\f31548\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\flominor\f31549\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\flominor\f31551\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\flominor\f31552\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\flominor\f31553\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\flominor\f31554\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\flominor\f31555\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\flominor\f31556\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}
{\fdbminor\f31558\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fdbminor\f31559\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}{\fdbminor\f31561\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}
{\fdbminor\f31562\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fdbminor\f31563\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}{\fdbminor\f31564\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}
{\fdbminor\f31565\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fdbminor\f31566\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}{\fhiminor\f31568\fbidi \fswiss\fcharset238\fprq2 Calibri CE{\*\falt Arial Rounded MT Bold};}
{\fhiminor\f31569\fbidi \fswiss\fcharset204\fprq2 Calibri Cyr{\*\falt Arial Rounded MT Bold};}{\fhiminor\f31571\fbidi \fswiss\fcharset161\fprq2 Calibri Greek{\*\falt Arial Rounded MT Bold};}
{\fhiminor\f31572\fbidi \fswiss\fcharset162\fprq2 Calibri Tur{\*\falt Arial Rounded MT Bold};}{\fhiminor\f31573\fbidi \fswiss\fcharset177\fprq2 Calibri (Hebrew){\*\falt Arial Rounded MT Bold};}
{\fhiminor\f31574\fbidi \fswiss\fcharset178\fprq2 Calibri (Arabic){\*\falt Arial Rounded MT Bold};}{\fhiminor\f31575\fbidi \fswiss\fcharset186\fprq2 Calibri Baltic{\*\falt Arial Rounded MT Bold};}
{\fhiminor\f31576\fbidi \fswiss\fcharset163\fprq2 Calibri (Vietnamese){\*\falt Arial Rounded MT Bold};}{\fbiminor\f31578\fbidi \froman\fcharset238\fprq2 Times New Roman CE;}{\fbiminor\f31579\fbidi \froman\fcharset204\fprq2 Times New Roman Cyr;}
{\fbiminor\f31581\fbidi \froman\fcharset161\fprq2 Times New Roman Greek;}{\fbiminor\f31582\fbidi \froman\fcharset162\fprq2 Times New Roman Tur;}{\fbiminor\f31583\fbidi \froman\fcharset177\fprq2 Times New Roman (Hebrew);}
{\fbiminor\f31584\fbidi \froman\fcharset178\fprq2 Times New Roman (Arabic);}{\fbiminor\f31585\fbidi \froman\fcharset186\fprq2 Times New Roman Baltic;}{\fbiminor\f31586\fbidi \froman\fcharset163\fprq2 Times New Roman (Vietnamese);}}
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{\*\docvar {TCDc1bVbRtcsaHPHNaAe}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Radiology" TableTitle="Radiology" NoDataText="No radiology found." GUID="eea33ff8-0dcc-4ed6-9926-77bfe0bf655a" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoData
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{\*\docvar {Th4psVmOW75BsMNMHkwH}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Urinalysis" TableTitle="Urinalysis" NoDataText="No urinalysis found." GUID="9f1f2d56-8727-43a7-8b81-f75c9cb4ff8e" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoD
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{\*\docvar {TiEhsAhee4vB8qDVgtki}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Haematology" TableTitle="Haematology" NoDataText="No haematology found." GUID="7dea4833-5a0d-4b19-8b7b-999d5ad6d3cc" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" 
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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 {TQX5FqPhVpIr52zZr4Jp}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Allergies" TableTitle="Allergies" NoDataText="No allergies recorded." GUID="e881db1c-e5f8-438d-a4f2-08404ef5e108" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoD
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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="75239b4c-0a2c-4376-bb32-d8a79f6da27c" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoData
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{\*\docvar {TUuuZpdetw6DgFxMkfaj}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="BMI" TableTitle="BMI" NoDataText="No BMI recorded." GUID="b2f683a5-a851-49e2-9c54-a0aea5b2e54a" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataAction="2" Tabl
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{\*\docvar {Tvxat5ulrnoJ3IdTsvHq}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Blood Pressure" TableTitle="Blood Pressure" NoDataText="No blood pressures recorded." GUID="c09f59df-f3f0-4384-9a34-d9a21b0fefcc" DisplayTitle="true" DisplayHeaderRow="true" DisplayBo
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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="52f41154-cc52-403a-9fdf-6e1ac040f33e" DisplayTitle="false" DisplayHeaderRow="fals
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{\*\docvar {TXZfR7AqcHLZ8hkluxnF}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Urea and electrolytes" TableTitle="Single Code Entry" NoDataText="No events found." GUID="f311c172-252a-4c7c-b9fe-8cb4ef1989d3" DisplayTitle="false" DisplayHeaderRo
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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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\fs22\insrsid3228556\charrsid11078984 {\*\bkmkend ICG_Priority}\nestcell{\nonesttables
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\ltrch\fcs0 \insrsid3228556\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3334\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
00020000140000001450626372696a6d6445557244696e3759534c423700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PbcrijmdEUrDin7YSLB7}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
NHS Number}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3344\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7010\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
0002000014000000145036774a4e4b6d626c3561776d664c524b76703500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P6wJNKmbl5awmfLRKvp5}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Title}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
0002000014000000145034757848633267326e6238446b52324e70684600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P4uxHc2g2nb8DkR2NphF}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Given Name}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
0002000014000000145058663437654f394d73506c794466486247336d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PXf47eO9MsPlyDfHbG3m}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Surname}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
000200001400000014506c63457835564f323677543331345931664b5100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlcEx5VO26wT314Y1fKQ}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Date of Birth}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
00020000140000001450624b474b66645344683779347879375a43556300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PbKGKfdSDh7y4xy7ZCUc}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Gender}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid11078984 {\*\datafield 
0002000014000000145070646c616e68433474754e456a35723269324800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PpdlanhC4tuNEj5r2i2H}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid11078984 
Ethnic Origin}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
00020000140000001450643162324831356e6a6a486c746a684771427300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pd1b2H15njjHltjhGqBs}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
000200001400000014504c6a394a506462574c764a39695969366d5a3500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PLj9JPdbWLvJ9iYi6mZ5}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Home Address Number and Street}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
00020000140000001450645738637468654650716e435642776469327900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PdW8ctheFPqnCVBwdi2y}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Home Address Village}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
0002000014000000145035397863694552493459446a6767796332787500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P59xciERI4YDjggyc2xu}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Home Address Town}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
00020000140000001450343568335435727338666365585731396c746300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P45h3T5rs8fceXW19ltc}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Home Address County}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
0002000014000000145039444a394b32357a766f64365953626f36666a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P9DJ9K25zvod6YSbo6fj}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Home Address Postcode}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid5918963\charrsid14885478 {\*\datafield 000200001400000014506c4c6f4463575a79446968535842416f4e634d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlLoDcWZyDihSXBAoNcM}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 Patient Home Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 {\*\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 \ltrch\fcs0 \insrsid5918963\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5918963\charrsid14885478 {\*\datafield 
000200001400000014506c7a527648785555644f46485a4a354b7a495300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlzRvHxUUdOFHZJ5KzIS}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5918963\charrsid14885478 
Patient Mobile Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid14885478 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 \ltrch\fcs0 \insrsid10043812\charrsid14885478  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10043812\charrsid14885478 {\*\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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid9403445\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9403445\charrsid14885478 {\*\datafield 
0002000014000000145050696c724e5456664643334e416a637537703900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PPilrNTVfFC3NAjcu7p9}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid14885478 
Patient E-mail Address}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9403445\charrsid14885478 {\*\bkmkend ICG_EmailAddress}
{\*\bkmkend PPilrNTVfFC3NAjcu7p9} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid14885478 \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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \cell \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3449\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6998\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5142252\charrsid11078984 {\*\datafield 
00020000140000001452725a784f6a754f35494734744c48527452577700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RrZxOjuO5IG4tLHRtRWw}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid5142252\charrsid11078984 
Referring User}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3449\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6998\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid11078984 {\*\datafield 
0002000014000000144641466c4744574a62636945344c43665058736a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname FAFlGDWJbciE4LCfPXsj}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid357474\charrsid11078984 
Free Text Prompt}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid357474\charrsid11078984 {\*\bkmkend FAFlGDWJbciE4LCfPXsj}{\*\bkmkend ICG_ReferrerCode} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid11078984 \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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3449\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6998\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\afs24 \ltrch\fcs0 \fs24\insrsid5918963\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 \fs24\insrsid5918963\charrsid14431031 
{\*\datafield 0002000014000000144f7a67724f31684c6a564462704f786744694a3200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname OzgrO1hLjVDbpOxgDiJ2}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 
\fs24\insrsid5918963\charrsid14431031 Organisation National Practice Code}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 
\fs24\insrsid3228556\charrsid14431031 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3356\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3449\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6998\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3449\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6998\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx3448\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx7027\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \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\charrsid11078984 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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid11167494\charrsid11078984 {\*\datafield 
00000000000000000d4943475f5370656369616c747900033257570000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_Specialty}{\*\ffdeftext 2WW}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid11167494\charrsid11078984 2WW}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3335\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx3448\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx7027\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \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\charrsid11078984 \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\afs24 \ltrch\fcs0 \fs24\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 \fs24\insrsid14431031\charrsid14431031 {\*\datafield 
00000000000000000e4943475f436c696e696354797065000b3257572055726f6c6f67790000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_ClinicType}{\*\ffdeftext 2WW Urology}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 
\fs24\lang1024\langfe1024\noproof\insrsid14431031\charrsid14431031 2WW Urology}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs24 \ltrch\fcs0 
\fs24\insrsid3228556\charrsid14431031 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3358\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx3448\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx7027\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \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\charrsid11078984 \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\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid11078984 {\*\datafield 
0000000000000000124943475f4e616d6564436c696e696369616e00000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_NamedClinician}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid11078984 \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\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx3448\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx7027\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx3448\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \cellx7027\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw22 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw22 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw22 \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\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx5121\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw22 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw22 \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\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx5120\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw22 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw22 \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\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth5342\clcbpatraw22 \cellx5234\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth5341\clcbpatraw22 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid9384172\charrsid14885478  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid14885478 {\*\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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid3478906\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid14885478 {\*\datafield 
000000001400000005546578743100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid14885478 \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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid14885478 Confidential/}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid10043812\charrsid14885478 Silent Referral}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid15753147\charrsid14885478 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid14885478 
\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 \ltrch\fcs0 \insrsid10043812\charrsid14885478  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10043812\charrsid14885478 {\*\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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 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 \ltrch\fcs0 \insrsid3478906\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid14885478 {\*\datafield 
00000000000000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid3478906\charrsid14885478 \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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid9384172\charrsid14885478  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid14885478 {\*\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\charrsid14885478 {\*\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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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 \ltrch\fcs0 \insrsid9384172\charrsid14885478  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid14885478 {\*\datafield 
000200001400000014505542535142555a49767365713433476c67764900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PUBSQBUZIvseq43GlgvI}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid14885478 
Main Language}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid14885478 {\*\bkmkend ICG_PreferredLanguage}{\*\bkmkend PUBSQBUZIvseq43GlgvI}
 }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9384172\charrsid14885478 \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\charrsid14885478 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\charrsid14885478 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 
\clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw22 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw22 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\charrsid11078984 Non-clinical information for the booking team:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid11078984 
\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 \ltrch\fcs0 \insrsid5579212\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5579212\charrsid11078984 {\*\datafield 00000000000000000e4943475f41646d696e4e6f74657300000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_AdminNotes}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\lang1024\langfe1024\noproof\insrsid5579212\charrsid11078984 \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\charrsid11078984 {\*\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\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\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\charrsid11078984 Provisional Diagnosis:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid11078984 
\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 {\*\bkmkstart ICG_ReferralReason
}{\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16334377\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16334377\charrsid11078984 {\*\datafield 
0000000000000000124943475f526566657272616c526561736f6e00000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_ReferralReason}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\lang1024\langfe1024\noproof\insrsid16334377\charrsid11078984 \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\charrsid11078984 {\*\bkmkend ICG_ReferralReason}\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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16334377\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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 \ltrch\fcs0 
\insrsid16334377\charrsid11078984 {\*\bkmkstart OLE_LINK1}{\*\bkmkstart OLE_LINK2}Smoking Status}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7210665\charrsid11078984 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid11078984 

\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 \ltrch\fcs0 \insrsid16334377\charrsid11078984  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16334377\charrsid11078984 {\*\datafield 
000200001400000014545846583256564272316475763244794566776500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TXFX2VVBr1duv2DyEfwe}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid11078984 
Single Code Entry: Smoking Status}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16334377\charrsid11078984 {\*\bkmkend ICG_SmokerCode}
{\*\bkmkend TXFX2VVBr1duv2DyEfwe}  }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid11078984 \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\charrsid11078984 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 
\trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat21\cltxlrtb\clftsWidth1\clcbpatraw21 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\charrsid11078984 \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\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrtbl \clcbpat22\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw22 \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\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb200\sa60\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid14431031 
\rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\cf6\lang9\langfe1033\kerning32\langnp9\insrsid14431031\charrsid14431031 If your patient does
 not meet any of the NICE defined 2WW criteria please liaise (by phone or Advice and Guidance) with a specialist or send them in as an urgent referral. Please do not annotate 2WW forms with your own criteria.}{\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\cf6\kerning32\insrsid14431031\charrsid14431031 
\par }{\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\kerning32\insrsid14431031\charrsid14431031 Patient Awareness
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 Confirm that your patient understands that they have been referred onto a \'93suspected cancer pathway\'94:\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\*\bkmkstart OLE_LINK3}{\*\bkmkstart OLE_LINK4}{\*\bkmkstart OLE_LINK5}{\*\bkmkstart OLE_LINK6}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10498323  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323 {\*\datafield 6680000000000000000000000000000000000000000021000300030000000a0006001a001e0013506c656173652073656c6563742062656c6f7703596573024e6f}
{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffdefres0{\*\ffl Please select below}{\*\ffl Yes}{\*\ffl No}}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 
{\*\bkmkend OLE_LINK3}{\*\bkmkend OLE_LINK4}{\*\bkmkend OLE_LINK5}{\*\bkmkend OLE_LINK6}{\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb
\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8\clhidemark \cellx1966\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 Confirm that your patient has received the }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7351999 HYPERLINK "http://www.valeofyorkccg.nhs.uk/rss/data/uploads/2ww-forms/patient-leaflet-2ww-final.pdf"}{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7351999\charrsid14431031 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90bca00000068007400740070003a002f002f007700770077002e00760061006c0065006f00660079006f0072006b006300630067002e006e00680073002e0075006b002f007200730073002f0064006100740061002f00
750070006c006f006100640073002f003200770077002d0066006f0072006d0073002f00700061007400690065006e0074002d006c006500610066006c00650074002d003200770077002d00660069006e0061006c002e007000640066000000795881f43b1d7f48af2c825dc485276300000000a5ab000308000000000000
0000000000}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \f0\ul\cf1\insrsid14431031\charrsid14431031 information leaflet}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031  (also available as }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
 HYPERLINK "http://www.scarboroughryedaleccg.nhs.uk/data/uploads/rss2/cancer/patient-leaflets/urgent-hospital-appointments-cancer-screening.pdf" }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid1975145\charrsid14431031 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90b2001000068007400740070003a002f002f007700770077002e00730063006100720062006f0072006f00750067006800720079006500640061006c0065006300630067002e006e00680073002e0075006b002f006400
6100740061002f00750070006c006f006100640073002f0072007300730032002f00630061006e006300650072002f00700061007400690065006e0074002d006c006500610066006c006500740073002f0075007200670065006e0074002d0068006f00730070006900740061006c002d006100700070006f0069006e0074
006d0065006e00740073002d00630061006e006300650072002d00730063007200650065006e0069006e0067002e007000640066000000795881f43b1d7f48af2c825dc485276300000000a5ab000300000000000000000000ff00ff}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\f0\ul\cf1\insrsid14431031\charrsid14431031 easy read}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 ):\cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323  FORMDROPDOWN }{\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323 {\*\datafield 6680000000000000000000000000000000000000000021000300030000000a0006001a001e0013506c656173652073656c6563742062656c6f7703596573024e6f}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox
\ffdefres0{\*\ffl Please select below}{\*\ffl Yes}{\*\ffl No}}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
\nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8\clhidemark \cellx1966\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid14431031\charrsid14431031 Confirm that your patient is available to attend an appointment within 2 weeks of this referral:\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10498323\charrsid10498323 {\*\datafield 6680000000000000000000000000000000000000000021000300030000000a0006001a001e0013506c656173652073656c6563742062656c6f7703596573024e6f}{\*\formfield{\fftype2\ffres25\fftypetxt0\ffhaslistbox\ffdefres0{\*\ffl 
Please select below}{\*\ffl Yes}{\*\ffl No}}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8\clhidemark \cellx1966\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8388\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 If, after discussion, your patient chooses to not}{\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\insrsid14431031\charrsid14431031  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 attend within 2 weeks, when will they be available:
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid14431031 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid14431031\charrsid14431031 \u8194\'20
\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8\clhidemark \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow3\irowband3\lastrow \ltrrow\ts11\trgaph108\trleft-108
\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\kerning32\insrsid14431031\charrsid14431031 Please tick any criteria that match the patient
\rquote s symptoms and give PSA results}{\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs16\kerning32\insrsid14431031\charrsid14431031 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid5119462\charrsid5119462 Unexplained visible haematuria (adult over 45) where a UTI has been excluded or persists or recurs after treatment of UTI}{\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}
}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid5119462\charrsid5119462 Non-visible haematuria (aged 60 or over) AND either dysuria or raised white cell count on a blood test}{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\bkmkstart OLE_LINK19}{\*\bkmkstart OLE_LINK20}Solid swellings in the body of the testis\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \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\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\bkmkend OLE_LINK19}{\*\bkmkend OLE_LINK20}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt
\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 Palpable renal mass}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 Solid renal}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid9716838  tract}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031  masses found on imaging}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid14431031\charrsid14431031 Abnormal feeling prostate on examination (any age) and PSA level }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid14431031\charrsid14431031 \u8194\'20
\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031  ng/ml}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 PSA over 10ng/ml (after exclusion of UTI) on one occasion in a man with a }{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid4617912\charrsid14431031 
ten-year}{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  life expectancy }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 
 FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang1024\langfe1024\noproof\langfenp2057\insrsid14431031\charrsid14431031 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  ng/ml\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst 
{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9716838\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 PSA above age-specific reference range, but below 10ng/ml in a man with a likely }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10498323\charrsid14431031 ten-year}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
 life expectancy (after exclusion of }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4617912 UTI}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 )
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 1}{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\super\langfenp2057\insrsid14431031\charrsid14431031 st}{\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  value }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang1024\langfe1024\noproof\langfenp2057\insrsid14431031\charrsid14431031 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  ng/ml }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang1024\langfe1024\noproof\langfenp2057\insrsid14431031\charrsid14431031 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  (date)
\par 2}{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\super\langfenp2057\insrsid14431031\charrsid14431031 nd}{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  value }{\field\fldedit{\*\fldinst {\rtlch\fcs1 
\af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\langfenp2057\insrsid14431031\charrsid14431031 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  ng/ml }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\langfenp2057\insrsid14431031\charrsid14431031 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031  (date) }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\cf6\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid9716838 not less than 6 weeks later}{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15682855 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\cf24\lang2057\langfe2057\langfenp2057\insrsid4617912\charrsid10498323 HYPERLINK "https://www.yorkhospitals.nhs.uk/our-services/a-z-of-services/lab-med/test-directory/clinical-biochemistry/prostate-specific-antigen/"}{\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\cf24\lang2057\langfe2057\langfenp2057\insrsid4617912\charrsid10498323 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90b24010000680074007400700073003a002f002f007700770077002e0079006f0072006b0068006f00730070006900740061006c0073002e006e00680073002e0075006b002f006f00750072002d007300650072007600
69006300650073002f0061002d007a002d006f0066002d00730065007200760069006300650073002f006c00610062002d006d00650064002f0074006500730074002d006400690072006500630074006f00720079002f0063006c0069006e006900630061006c002d00620069006f006300680065006d0069007300740072
0079002f00700072006f00730074006100740065002d00730070006500630069006600690063002d0061006e0074006900670065006e002f000000795881f43b1d7f48af2c825dc485276300000000a5ab00030000000000000000}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\f0\ul\cf24\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid10498323 (40-49y: 0-2, 50-59y: 0-3, 60-69y: 0-4, >70y: 0-5 ng/ml)}}}\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 
\af37 \ltrch\fcs0 \b\cf24\lang2057\langfe2057\langfenp2057\insrsid15682855 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \cf6\insrsid15682855\charrsid4617912 A UTI has been excluded (mandatory for 2ww pathway)}{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\cf6\lang2057\langfe2057\langfenp2057\insrsid15682855\charrsid15682855 \cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\*\bkmkstart _Hlk527446707}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
 FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 
{\*\bkmkend _Hlk527446707}{\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh
\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4177\trftsWidthB2\trftsWidthA2\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid15682855\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid15682855 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \cf6\insrsid15682855\charrsid15682855 
 FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \cf6\insrsid15682855\charrsid15682855 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \cf6\insrsid15682855\charrsid15682855 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid15682855\charrsid14431031 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\tpvpara\tphmrg\tposy1250\tdfrmtxtLeft180\tdfrmtxtRight180\trftsWidth2\trwWidth4106\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tabsnoovrlp1\tblrsid15682855
\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 
\clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx993\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9716838\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow7\irowband7\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9716838\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow8\irowband8\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 Any suspected penile cancer\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}
\sectd \ltrsect\margtsxn720\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1010\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow8\irowband8\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow8\irowband8\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalb\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth9254\clcbpatraw22\clhidemark \cellx9146\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth1429\clcbpatraw22\clhidemark \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \b\insrsid14431031\charrsid14431031 \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sb200\sa60\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid14431031 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid14431031\charrsid14431031 Additional Information
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\bkmkstart _Hlk15300292}Please tick to confirm U+Es have been requested (if not done in the last three months)
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \i\insrsid14431031\charrsid14431031 They are needed to enable rapid MRI scanning\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid14431031 
{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 01000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft701\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv
\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth2752\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind696\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl
\brdrs\brdrw10\brdrcf20 \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx1693\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone 
\clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr
\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 {\*\bkmkend _Hlk15300292}Please consider giving patients with raised PSA one of the information }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
 HYPERLINK "https://www.valeofyorkccg.nhs.uk/rss/index.php?id=urology" }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid1975145\charrsid14431031 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90b8c000000680074007400700073003a002f002f007700770077002e00760061006c0065006f00660079006f0072006b006300630067002e006e00680073002e0075006b002f007200730073002f0069006e0064006500
78002e007000680070003f00690064003d00750072006f006c006f00670079000000795881f43b1d7f48af2c825dc485276300000000a5ab000300000000000000850000008500}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \f0\ul\cf1\insrsid14431031\charrsid14431031 sheets}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \cell \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 \trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 
\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth8655\clcbpatraw22\clhidemark \cellx8547\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrnone 
\clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth2028\clcbpatraw22 \cellx10575\row \ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 Any additional comments / history of this presentation:
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid14431031 {\*\bkmkstart _Hlk15381146}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031  FORMTEXT }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16741 \u8194\'20\u8194\'20\u8194\'20
\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\bkmkend _Hlk15381146}
\nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 {\*\nesttableprops
\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf20 \trbrdrl\brdrs\brdrw10\brdrcf20 \trbrdrb\brdrs\brdrw10\brdrcf20 \trbrdrr\brdrs\brdrw10\brdrcf20 \trbrdrh\brdrs\brdrw10\brdrcf20 \trbrdrv\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 \clbrdrl\brdrs\brdrw10\brdrcf20 \clbrdrb
\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrs\brdrw10\brdrcf20 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8\clhidemark \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14431031 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid14431031\charrsid14431031 \trowd \irow2\irowband2\lastrow \ltrrow\ts11\trgaph108\trleft-108
\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf20 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14431031\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf20 
\clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf20 \clbrdrr\brdrnone \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6105807 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\kerning32\insrsid6105807 
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10\brdrcf6 \trbrdrl\brdrs\brdrw10\brdrcf6 \trbrdrb\brdrs\brdrw10\brdrcf6 \trbrdrr\brdrs\brdrw10\brdrcf6 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4617912\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf6 \clbrdrl
\brdrs\brdrw10\brdrcf6 \clbrdrb\brdrs\brdrw10\brdrcf6 \clbrdrr\brdrs\brdrw10\brdrcf6 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\pard \ltrpar\qj \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid4617912 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4617912\charrsid4617912 An MRI form is appended to this referral template. It is not for GPs to complete or sign.
\par It is to help the urologists rapidly order an MRI when they feel that\rquote s indicated because most details will have been automatically completed by GP computer systems.
\par 
\par Not all patients need an MRI but it will speed up secondary care investigations if primary care referrers complete blue boxes and secondary care will complete the grey boxes.}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4617912\charrsid14431031 \cell 
}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4617912\charrsid14431031 \trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft-108
\trbrdrt\brdrs\brdrw10\brdrcf6 \trbrdrl\brdrs\brdrw10\brdrcf6 \trbrdrb\brdrs\brdrw10\brdrcf6 \trbrdrr\brdrs\brdrw10\brdrcf6 
\trftsWidth2\trwWidth5000\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4617912\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf6 \clbrdrl
\brdrs\brdrw10\brdrcf6 \clbrdrb\brdrs\brdrw10\brdrcf6 \clbrdrr\brdrs\brdrw10\brdrcf6 \clcbpat22\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw22\clhidemark \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\brdrb\brdrs\brdrw10\brsp20 
\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6105807 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\kerning32\insrsid4617912 
\par }{\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 \b\fs28\kerning32\insrsid14431031\charrsid14431031 Generic Patient Clinical Details
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\bkmkstart T3KrqOhuscI2fGRF7Dvt}Patient Name:}{
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\bkmkend T3KrqOhuscI2fGRF7Dvt} {\*\bkmkstart Py59AkpI3akbBr2SU9Uz}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 
{\*\datafield 00020000140000001450793539416b704933616b62427232535539557a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Py59AkpI3akbBr2SU9Uz}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 Title}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\bkmkend Py59AkpI3akbBr2SU9Uz} {\*\bkmkstart PjxtOV1VbRDDJhTcVEMH}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\datafield 000200001400000014506a78744f563156625244444a68546356454d4800000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PjxtOV1VbRDDJhTcVEMH}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 Given Name}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\bkmkend PjxtOV1VbRDDJhTcVEMH} {\*\bkmkstart PYOcOrY1SyjmhgHVUoQ5}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\datafield 00020000140000001450594f634f72593153796a6d68674856556f513500000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PYOcOrY1SyjmhgHVUoQ5}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 Surname}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\bkmkend PYOcOrY1SyjmhgHVUoQ5} }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid14431031\charrsid14431031 \line {\*\bkmkstart TOxewwtuwoHmdpdnX2DH}Date of Birth: {\*\bkmkstart PILIFoxdSwF1VTg8Dm6G}{\*\bkmkend TOxewwtuwoHmdpdnX2DH}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\datafield 00020000140000001450494c49466f78645377463156546738446d364700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PILIFoxdSwF1VTg8Dm6G}}}}}{\fldrslt {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid14431031 Date of Birth}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 
{\*\bkmkend PILIFoxdSwF1VTg8Dm6G} }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \line {\*\bkmkstart TNwoTK1gbsondiKIoIX8}NHS number: {\*\bkmkstart PLSBkfbqnZ49xLOKefZK}{\*\bkmkend TNwoTK1gbsondiKIoIX8}}{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\datafield 000200001400000014504c53426b6662716e5a3439784c4f4b65665a4b00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20
{\*\ffname PLSBkfbqnZ49xLOKefZK}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 NHS Number}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid14431031 {\*\bkmkend PLSBkfbqnZ49xLOKefZK} }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid14431031\charrsid14431031 Summary Problems List
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\*\bkmkstart TuIMbh38BampUTbynRfV}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 0002000014000000145475494d6268333842616d70555462796e52665600000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TuIMbh38BampUTbynRfV}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 Problems}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\bkmkend TuIMbh38BampUTbynRfV}
\par }\pard \ltrpar\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid14431031\charrsid14431031 Current Repeat Medication List
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\*\bkmkstart TkKfSjIKDItl8fmzwf7A}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid14431031\charrsid14431031  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\datafield 000200001400000014546b4b66536a494b4449746c38666d7a7766374100000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TkKfSjIKDItl8fmzwf7A}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 Medication}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 {\*\bkmkend TkKfSjIKDItl8fmzwf7A}
\par }\pard \ltrpar\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid14431031\charrsid14431031 Allergies & Sensitivities
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\*\bkmkstart TQX5FqPhVpIr52zZr4Jp}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031  FORMTEXT }{
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\datafield 00020000140000001454515835467150685670497235327a5a72344a7000000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TQX5FqPhVpIr52zZr4Jp}}}}}{\fldrslt {\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid14431031 Allergies}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031 {\*\bkmkend TQX5FqPhVpIr52zZr4Jp} 
}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af0\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid14431031\charrsid14431031 Most Recent BMI
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\*\bkmkstart T8kgfHZBgds5gjTfEypJ}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16741  FORMTEXT }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16741 {\*\datafield 00020000140000001454386b6766485a4267647335676a54664579704a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T8kgfHZBgds5gjTfEypJ}}}}}{\fldrslt {\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid16741 Single Code Entry: Body mass index}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid16741 
{\*\bkmkend T8kgfHZBgds5gjTfEypJ}  }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid14431031\charrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \ab\af37\afs28 \ltrch\fcs0 \b\fs28\insrsid14431031\charrsid14431031 
Most Recent Blood Pressure}{\rtlch\fcs1 \ab\af37\afs28 \ltrch\fcs0 \b\fs28\insrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid16741 \~{\*\bkmkstart TZYj7beMKkYchkFIdOt9}}{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af37 \ltrch\fcs0 \f31506\insrsid16741\charrsid16741  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \f31506\insrsid16741\charrsid16741 {\*\datafield 000200001400000014545a596a3762654d4b6b5963686b4649644f743900000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TZYj7beMKkYchkFIdOt9}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \f31506\insrsid16741\charrsid16741 Blood Pressure}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \f31506\insrsid16741\charrsid16741 {\*\bkmkend TZYj7beMKkYchkFIdOt9} }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\f31506\insrsid14431031\charrsid16741 
\par }\pard \ltrpar\ql \li0\ri0\sb240\sa240\sl276\slmult1\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16741 {\rtlch\fcs1 \af37\afs28 \ltrch\fcs0 \b\fs28\insrsid14431031\charrsid14431031 
Smoking Statu}{\rtlch\fcs1 \af37\afs28 \ltrch\fcs0 \b\fs28\insrsid14431031 s}{\rtlch\fcs1 \af37\afs28 \ltrch\fcs0 \b\fs28\insrsid14431031\charrsid16741 
\par }\pard \ltrpar\ql \li0\ri0\sb240\sa240\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323  FORMTEXT }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid10498323 \u8194\'20
\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12453711 
\par }\pard \ltrpar\ql \li0\ri0\sb240\sa240\sl276\slmult1\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10498323 {\rtlch\fcs1 \af37\afs28 \ltrch\fcs0 \b\fs28\insrsid10498323\charrsid10498323 
Other Clinical Relevant Detail}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323  }{\rtlch\fcs1 \af37\afs26 \ltrch\fcs0 \fs26\insrsid10498323\charrsid10498323 (include carer details if relevant)}{\rtlch\fcs1 \af37\afs26 \ltrch\fcs0 \fs26\insrsid10498323 

\par }\pard \ltrpar\ql \li0\ri0\sb240\sa240\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid14431031  FORMTEXT }{
\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid14431031 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323 \u8194\'20\u8194\'20\u8194
\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10498323\charrsid14431031 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14431031\charrsid14431031 \page 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11953492\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat26\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw26\clhidemark \cellx10575\pard\plain \ltrpar\qc \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid11953492\charrsid11953492 {\*\bkmkstart _Hlk527625699}YORK TEACHING HOSPITAL NHS TRUST
\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\cf21\insrsid11953492\charrsid11953492 Urology 2WW Prostate/Pelvis MRI Scan Referral
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11953492\charrsid11953492 Authorised referrers }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\b\f1\insrsid11953492\charrsid11953492 ONLY}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11953492\charrsid11953492  must complete }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid11953492\charrsid11953492 ALL}{\rtlch\fcs1 \af1 \ltrch\fcs0 
\f1\insrsid11953492\charrsid11953492  non \'93Radiology only\'94 sections on this page\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 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid11953492\charrsid14431031 \trowd \irow0\irowband0\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11953492\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone 
\clcbpat26\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw26\clhidemark \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11953492\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\pard\plain \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\cf6\insrsid11953492\charrsid11953492 WARNING}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \f1\fs28\cf6\insrsid11953492\charrsid11953492  - }{\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \f1\fs18\cf6\insrsid11953492\charrsid11953492 Incomplete or illegible requests could delay this examination or result in an incomplete investigation}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \f1\fs28\cf6\insrsid11953492\charrsid11953492 
\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 
\af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid11953492\charrsid14431031 \trowd \irow1\irowband1\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid11953492\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw27 \cellx5954\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat28\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw28 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\cf6\insrsid11953492\charrsid11953492 Primary care referrers please complete blue boxes\cell Secondary care complete grey boxes\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 
\af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid11953492\charrsid14431031 \trowd \irow2\irowband2\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 
\clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw27 \cellx5954\clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat28\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw28 \cellx10575\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw27 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10\brdrcf27 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid11953492\charrsid11953492 Patient Information}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid11953492 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 Patient Name:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PjeirhQTksrnLPPqqd5U}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 {\*\datafield 000200001400000014506a6569726851546b73726e4c5050717164355500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname 
PjeirhQTksrnLPPqqd5U}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 Full Name}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 
\af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 {\*\bkmkend PjeirhQTksrnLPPqqd5U} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par NHS Number:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart P25JWhj9cL9wIeSHFurs}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 0002000014000000145032354a57686a39634c3977496553484675727300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P25JWhj9cL9wIeSHFurs}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 NHS Number}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 
{\*\bkmkend P25JWhj9cL9wIeSHFurs} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par DOB:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PjtZvjGdFjuFTgO7w24a}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 000200001400000014506a745a766a4764466a754654674f377732346100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PjtZvjGdFjuFTgO7w24a}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 Date of Birth}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 
{\*\bkmkend PjtZvjGdFjuFTgO7w24a} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par Gender:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PF3rHxTkO9QaktAf2Q3U}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 000200001400000014504633724878546b4f3951616b7441663251335500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PF3rHxTkO9QaktAf2Q3U}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 Gender}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 {\*\bkmkend PF3rHxTkO9QaktAf2Q3U
} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par Address:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PapvuieEu2jdFWakHucz}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 000200001400000014506170767569654575326a644657616b4875637a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PapvuieEu2jdFWakHucz}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 Home Full Address (stacked)}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 
{\*\bkmkend PapvuieEu2jdFWakHucz} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par Telephone Number:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PzVwu57q7QrveBz399V5}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 000200001400000014507a5677753537713751727665427a333939563500000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PzVwu57q7QrveBz399V5}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 Patient Home Telephone}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 
{\*\bkmkend PzVwu57q7QrveBz399V5} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 
\par Mobile Number:}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  {\*\bkmkstart PK9rp3vQ9lOmjwFHQh3s}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 {\*\datafield 000200001400000014504b397270337651396c4f6d6a7746485168337300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PK9rp3vQ9lOmjwFHQh3s}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 
\f0\fs24\insrsid11953492 Patient Mobile Telephone}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid11953492 
{\*\bkmkend PK9rp3vQ9lOmjwFHQh3s} }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492\charrsid11953492 \cell }\pard \ltrpar\ql \li0\ri0\sb40\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid6823589\yts25 {\rtlch\fcs1 \af1\afs18 
\ltrch\fcs0 \f1\fs18\insrsid11953492\charrsid11953492 
Patients need to be able to reliably answer safety questions prior to MRI (about metal foreign bodies and implants etc). If their cognition is impaired and they may not be able to do this extra time is allowed for plain film testing prior to MRI so\'85}{
\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid11953492 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid11953492 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492 Is the patient able to independently answer MRI Safety Screening questions}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492 ?  }{\rtlch\fcs1 \af1\afs24 
\ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 Y}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492  FORMCHECKBOX 
}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492  }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid11953492\charrsid11953492 N}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492   }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492  FORMCHECKBOX }{
\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid11953492\charrsid11953492 \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 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid11953492\charrsid14431031 \trowd \irow3\irowband3\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 
\trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw27 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10\brdrcf27 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 \cellx10575\row \ltrrow}\trowd \irow4\irowband4\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw28 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf27 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid11953492\charrsid11953492 Examination requested}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid11953492 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11953492 Prostate / Pelvis
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 Free text: }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid16741 \u8194\'20\u8194\'20\u8194\'20\u8194\'20
\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492 
\par Patient is on a fast track pathway? }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492 {\*\datafield 
65000000140000000000010000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres1}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {
\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492  Yes}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 
{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492 Does the patient have an implanted device which may be a contraindication to MRI? }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 Y}{\rtlch\fcs1 \af1\afs24 
\ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\i\f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492  }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid11953492\charrsid11953492 N}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492   }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492 
 FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492 
\par If so, what are they? }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 {\*\datafield 
00000000140000000000000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10498323 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11953492\charrsid11953492 \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 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid11953492\charrsid14431031 \trowd \irow4\irowband4\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 
\trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw28 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf27 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 \cellx10575\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw28 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid12453711\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid12453711 Clinical details and diagnosis:
\par }{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  FORMTEXT }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 00000000140000000000000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid16741 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid11953492\yts25 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 Is the patient known to have severe renal impairment (defined }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\f1\fs24\insrsid10498323 eGFR}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711  <30ml/min/}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711\charrsid12453711 m}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\f1\fs24\super\insrsid10498323\charrsid10498323 2}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 )? }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\cf6\insrsid12453711\charrsid12453711 (Mandatory)}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\f1\fs24\insrsid12453711 
\par }\pard \ltrpar\qc \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid12453711\yts25 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711 Yes}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711  }{\rtlch\fcs1 
\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711 No}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711   }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 
\par 
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid12453711\yts25 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711\charrsid12453711 If }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid12453711\charrsid12453711 
yes EITHER}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711\charrsid12453711 : provide Egfr (<3 months old)}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711 
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid12453711\charrsid12453711 *eGFR}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711 :}{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid6823589  {\*\bkmkstart TPnKN1Mdq1fKgwGw2WUa}}{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid6823589  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid6823589 {\*\datafield 00020000140000001454506e4b4e314d647131664b677747773257556100000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TPnKN1Mdq1fKgwGw2WUa}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid2195411 Single Code Entry: eGFR using creatinine (CKD-EPI) per 1.73 square metres}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid6823589 {\*\bkmkend TPnKN1Mdq1fKgwGw2WUa}  }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\f1\insrsid12453711 
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid12453711\charrsid12453711 OR:}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid12453711 
\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711\charrsid12453711 Tick box }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \i\f1\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1 \ltrch\fcs0 
\i\f1\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12453711\charrsid12453711  to indicate eGFR being ordered
\par }\pard \ltrpar\ql \li0\ri0\sa40\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid6823589\yts25 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\cf6\insrsid12453711\charrsid12453711 Request may not be processed until results are available to us}{
\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \b\f0\fs24\cf6\insrsid12453711\charrsid12453711 \~\~ }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\cf6\insrsid12453711\charrsid12453711 \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 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid12453711\charrsid14431031 \trowd \irow5\irowband5\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 
\trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth6062\clcbpatraw28 \cellx5954\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth4621\clcbpatraw27 
\cellx10575\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat27\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw27 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sb80\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid6823589\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 
\f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711\charrsid12453711 Disability?}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711  }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid12453711\charrsid12453711 Yes }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  Hearing }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid12453711\charrsid12453711  Visual }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  Learning}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\f1\fs24\insrsid12453711  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\i\f1\fs24\insrsid12453711\charrsid12453711 
{\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 
\par }\pard \ltrpar\ql \li0\ri0\sa80\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid6823589\yts25 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711 Please describe mobility: }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid12453711\charrsid12453711 Walking }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  Trolley }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid12453711\charrsid12453711  Chair }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  Bed }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\insrsid12453711\charrsid12453711  Hoist }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711\charrsid12453711  O}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\sub\insrsid10498323 2}{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \f1\fs16\insrsid12453711\charrsid12453711  }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 
\af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \f1\fs16\insrsid12453711\charrsid12453711 \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 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid12453711\charrsid14431031 \trowd \irow6\irowband6\ltrrow\ts25\trgaph108\trrh566\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 
\trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 
\clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw27 \cellx10575\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr
\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl
\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw28 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid12453711\yts25 \rtlch\fcs1 
\af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f1\fs22\insrsid12453711\charrsid12453711 Referring Clinician}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711  
}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \f1\fs14\insrsid12453711\charrsid12453711 Requests only accepted from Trust approved referrers - Ionising Radiation (Medical Exposure) Regulations 2000}{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \f1\fs14\insrsid12453711 

\par 
\par 
\par }{\rtlch\fcs1 \af1\afs14 \ltrch\fcs0 \b\f1\fs14\insrsid12453711\charrsid12453711 
\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid12453711\charrsid12453711 Responsible Consultant}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12453711                                                  }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\b\f1\fs24\insrsid12453711\charrsid12453711 Date of referral:\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 \af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid12453711\charrsid14431031 \trowd \irow7\irowband7\ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt
\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 
\trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 
\clcbpat28\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw28 \cellx10575\row \ltrrow}\trowd \irow8\irowband8\ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw27 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid13723826\yts25 \rtlch\fcs1 
\af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\cf6\insrsid12453711\charrsid12453711 Weight:}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 
\f1\fs24\cf6\insrsid12453711\charrsid12453711  {\*\bkmkstart TnhAOx22npZhtzxWaJmz}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\cf6\chshdng0\chcfpat0\chcbpat27\insrsid12453711\charrsid16741  FORMTEXT }{\rtlch\fcs1 \af1\afs24 
\ltrch\fcs0 \f1\fs24\cf6\chshdng0\chcfpat0\chcbpat27\insrsid12453711\charrsid16741 {\*\datafield 000200001400000014546e68414f7832326e705a68747a7857614a6d7a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname 
TnhAOx22npZhtzxWaJmz}}}}}{\fldrslt {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\cf6\chshdng0\chcfpat0\chcbpat27\insrsid12453711\charrsid16741 Single Code Entry: O/E - weight}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\cf6\insrsid12453711\charrsid12453711 {\*\bkmkend TnhAOx22npZhtzxWaJmz}  (Mandatory)\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 
\af37\afs20 \ltrch\fcs0 \fs20\lang2057\langfe2057\langfenp2057\insrsid12453711\charrsid14431031 \trowd \irow8\irowband8\ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 
\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 
\clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat27\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw27 \cellx10575\row \ltrrow}\trowd \irow9\irowband9\lastrow \ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt
\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw28 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sb120\sl360\slmult1
\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid6823589\yts25 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\f1\fs18\insrsid12453711\charrsid12453711 For Radiology Use Only}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid12453711                                                }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\f1\fs18\insrsid12453711\charrsid12453711 In }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid12453711\charrsid12453711  Out }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\f1\fs18\insrsid12453711\charrsid12453711  List }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \i\f1\fs24\insrsid12453711\charrsid12453711  }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\f1\fs18\insrsid12453711\charrsid12453711   
\par }\pard \ltrpar\ql \li0\ri0\sl360\slmult1\widctlpar\intbl\wrapdefault\nooverflow\faauto\rin0\lin0\pararsid13723826\yts25 {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid12453711 
Authorised by:                                                         Urgent }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid12453711  Soon }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid12453711  Routine }
{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid12453711\charrsid12453711  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid12453711\charrsid12453711 {\*\datafield 
65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {
\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid13723826 
\par Practitioner:
\par Operator:                                                                                  Scan type:
\par Comments:
\par IV Contrast: }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid13723826 Y }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\i\f1\fs18\insrsid13723826\charrsid13723826 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid13723826  N }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\i\f1\fs18\insrsid13723826\charrsid13723826  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826 {\*\datafield 65000000140000000000000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20
\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid13723826 
                                                             }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid13723826 Oral Contrast: }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid13723826 Y }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 
\af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826 {\*\datafield 01000000140000000000000000000000000000000000}
{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 
\b\f1\fs18\insrsid13723826  N }{\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826  FORMCHECKBOX }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\i\f1\fs18\insrsid13723826\charrsid13723826 
{\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj {
\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \b\f1\fs18\insrsid13723826 
\par }{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid13723826 Radiology appointment date & time:}{\rtlch\fcs1 \af1\afs18 \ltrch\fcs0 \f1\fs18\insrsid13723826\charrsid13723826 \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 \af37\afs20 \ltrch\fcs0 
\fs20\lang2057\langfe2057\langfenp2057\insrsid12453711\charrsid14431031 \trowd \irow9\irowband9\lastrow \ltrrow\ts25\trgaph108\trrh306\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh
\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16741\tbllkhdrrows\tbllkhdrcols\tbllknocolband\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb
\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat28\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw28 \cellx10575\row }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14431031 {
\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid16741 {\*\bkmkend _Hlk527625699}\sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid6105807\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10498323 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\b\insrsid6105807\charrsid14431031 
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a

00000021000dd1909fb60000001b0100002700000000000000000000000000b20900007468656d652f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73504b050600000000050005005d010000ad0a00000000}
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