<EMISWebDocTemplate><DisplayGroups></DisplayGroups><DefaultDocumentType></DefaultDocumentType><DocumentTypeCodeSystem></DocumentTypeCodeSystem><Description>Stroke Service Form</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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{\*\docvar {Td8HbRxBQFZprfzZGLki}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Urinalysis" TableTitle="Urinalysis" NoDataText="No urinalysis found." GUID="04a3dd9a-fb8a-4717-a8a1-d78a52f2137e" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoD
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{\*\docvar {TDGBhoKbvcjHwTqIHsni}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Tissue transglutaminase IgA level" TableTitle="Single Code Entry" NoDataText="No Coeliac serology result recorded." GUID="4b03360d-c208-4151-b095-d7b18066a60b" Disp
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{\*\docvar {TerMECGcyo4EvpepHkbd}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Serum ferritin" TableTitle="Single Code Entry" NoDataText="No Ferritin levels recorded." GUID="01c445e6-ecd4-41e0-9656-fa7169b7ef9c" DisplayTitle="false" DisplayHea
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{\*\docvar {TeWqZa3YXgaE8wuyfgul}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Haemoglobin estimation" TableTitle="Single Code Entry" NoDataText="No Hb results recorded." GUID="1ff91c11-de6b-4c1e-b7ab-1762f4c85ca2" DisplayTitle="false" Display
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{\*\docvar {TFDiGhuXDMIcbDA6Z1xP}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Medication" TableTitle="Medication" NoDataText="No medication issued." GUID="ae6db609-8b90-4e76-9a41-c924b9cd1723" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" No
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{\*\docvar {TfEDcoe5gDG6ifFW2p5P}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Haemoglobin A1c level - IFCC standardised" TableTitle="Single Code Entry" NoDataText="No Hb recorded." GUID="bc0839e0-6113-4cc7-842f-0ed323bf37da" DisplayTitle="fal
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{\*\docvar {Tgdc14ILEvrUhZO5Vyif}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Erythrocyte sedimentation rate" TableTitle="Single Code Entry" NoDataText="No events found." GUID="0c5598e1-5c4e-48ed-a7ae-ef5dfcd0423c" DisplayTitle="false" Displa
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{\*\docvar {TgL1PDamL6QmYjGTnpC8}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Haemoglobin A1c level - IFCC standardised" TableTitle="Single Code Entry" NoDataText="No Hb level recorded." GUID="ef5cb9d5-62b8-4759-9c97-ca2af7f66c71" DisplayTitl
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{\*\docvar {TGZTAXJ2TAFu2mYeZp49}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Smoking Status" TableTitle="Single Code Entry" NoDataText="No events found." GUID="0faa4765-da35-45fa-98b3-3b2ea5258ff5" DisplayTitle="false" DisplayHeaderRow="fals
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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 {TH4VEXQh3YYIeFnoiBeA}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Total alkaline phosphatase" TableTitle="Single Code Entry" NoDataText="No events found." GUID="888d4075-30cb-45c1-8a41-cc300a1df210" DisplayTitle="false" DisplayHea
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{\*\docvar {THFrcHkYc8lxzoiF4heF}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Haemoglobin A1c level - IFCC standardised" TableTitle="Single Code Entry" NoDataText="No Hb recorded." GUID="4fa7abc6-0516-4f5f-9f85-b07381f165d1" DisplayTitle="fal
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{\*\docvar {Tji2Cbm4xf8S6h9XcaUc}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Alcohol Consumption" TableTitle="Alcohol Consumption" NoDataText="No alcohol consumption entries recorded." GUID="e9d33c91-dede-4b04-9441-d5e4142afa2b" DisplayTitle="true" DisplayHead
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{\*\docvar {TKc8qZZLzofqMMBuDUNP}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Peak Flow" TableTitle="Peak Flow" NoDataText="No peak flows recorded." GUID="0cd00752-c339-4913-9e71-c2069aabd530" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" No
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{\*\docvar {TNwoTK1gbsondiKIoIX8}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Religion" TableTitle="Single Code Entry" NoDataText="No events found." GUID="49a08dfe-c1e7-4a17-a52e-e215a272f390" DisplayTitle="false" DisplayHeaderRow="false" Dis
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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 {TPsMaMslqJ532AieIxqB}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Medication" TableTitle="Medication" NoDataText="No medication issued." GUID="4f956b87-5ea2-4845-a99a-7e35c87c84df" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" No
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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 {TqhIvmM11vIno7hd581D}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="BMI" TableTitle="BMI" NoDataText="No BMI recorded." GUID="9feff4cd-2098-4e91-b113-1a02f1cd1b74" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder="false" NoDataAction="2" Tabl
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{\*\docvar {TQJSRxLlyG8xrb7qNCOd}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Serum C reactive protein level" TableTitle="Single Code Entry" NoDataText="No CRP results recorded." GUID="ed775663-3e0b-41cd-92c6-c599777d9fa6" DisplayTitle="false
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{\*\docvar {TsqQcZwQzxoL2DxA9ucT}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Consultations" TableTitle="Consultations" NoDataText="No consultations recorded." GUID="20d8ea50-d2b8-47e3-97c5-a45e5a7ee4ef" DisplayTitle="true" DisplayHeaderRow="true" DisplayBorder
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{\*\docvar {TST4kDgHOCvcdtp2NaBh}{T<ClinicalContentTableType IncludeMostRecentOnly="false" UIDisplayName="Single Code Entry: Serum ferritin" TableTitle="Single Code Entry" NoDataText="No Ferritin levels recorded." GUID="01c445e6-ecd4-41e0-9656-fa7169b7ef9c" DisplayTitle="false" DisplayHea
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\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar
\ql \li0\ri0\keepn\widctlpar\wrapdefault\nooverflow\faauto\outlinelevel0\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \ab\af37\afs28 \ltrch\fcs0 
\b\fs28\kerning32\insrsid3817048\charrsid3817048 If more than one episode of TIA within 7 days (crescendo TIA) then GP to refer patient to ED/ED refer to local HASU Team.
\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3817048 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\fs28\insrsid3817048\charrsid3817048 
If any queries please contact the On Call Stroke Consultant via switchboard
\par }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3228556\charrsid1994260 Reference/Priority
\par \ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 Referral Date:
\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 RXgXRYoujlS5T1fabezz}{\*\bkmkstart ICG_ReferralDate}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
0002000014000000145258675852596f756a6c53355431666162657a7a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RXgXRYoujlS5T1fabezz}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Referral Date}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend RXgXRYoujlS5T1fabezz}{\*\bkmkend ICG_ReferralDate} }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \cell Priority:
\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 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10712497 {\*\bkmkstart ICG_Priority}Urgent}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 {\*\bkmkend ICG_Priority}\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3335\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PkBIgVFpF2ObDippdjg7}{\*\bkmkstart ICG_NHSNumber}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506b42496756467046324f6244697070646a673700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PkBIgVFpF2ObDippdjg7}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 NHS Number}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PkBIgVFpF2ObDippdjg7}{\*\bkmkend ICG_NHSNumber} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 Pg1cE6CkGqmTGWNQed7N}{\*\bkmkstart ICG_PreNominal}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506731634536436b47716d5447574e516564374e00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pg1cE6CkGqmTGWNQed7N}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Title}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend Pg1cE6CkGqmTGWNQed7N}{\*\bkmkend ICG_PreNominal} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PEVTqB3LiXk2wEODUIhv}{\*\bkmkstart ICG_Forenames}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014504556547142334c69586b3277454f445549687600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PEVTqB3LiXk2wEODUIhv}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Given Name}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PEVTqB3LiXk2wEODUIhv}{\*\bkmkend ICG_Forenames} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 POwXaaZxlMcRu938iFoh}{\*\bkmkstart ICG_Surname}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014504f775861615a786c4d63527539333869466f6800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname POwXaaZxlMcRu938iFoh}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Surname}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 {\*\bkmkend POwXaaZxlMcRu938iFoh}{\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 PoBZJ5W94NoeQx7oRjHn}{\*\bkmkstart ICG_DateOfBirth}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506f425a4a355739344e6f655178376f526a486e00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PoBZJ5W94NoeQx7oRjHn}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Date of Birth}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PoBZJ5W94NoeQx7oRjHn}{\*\bkmkend ICG_DateOfBirth} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3327\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PlGVUU5wZIrUwU87xfuM}{\*\bkmkstart ICG_Gender}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506c4756555535775a497255775538377866754d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlGVUU5wZIrUwU87xfuM}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Gender}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PlGVUU5wZIrUwU87xfuM}{\*\bkmkend ICG_Gender} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 P3ARayhaoqcDTNhMNhhb}{\*\bkmkstart ICG_Ethnicity}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
00020000140000001450334152617968616f716344544e684d4e68686200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P3ARayhaoqcDTNhMNhhb}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Ethnic Origin}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend P3ARayhaoqcDTNhMNhhb}{\*\bkmkend ICG_Ethnicity} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3343\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3440\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7011\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 PksYSSWxuTEfEtpL7DBf}{\*\bkmkstart ICG_Address1}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506b735953535778755445664574704c3744426600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PksYSSWxuTEfEtpL7DBf}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Home Address House Name/Flat Number}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PksYSSWxuTEfEtpL7DBf}{\*\bkmkend ICG_Address1} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PHCWZMHiKFQVfbVWrlqo}{\*\bkmkstart ICG_Address2}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014504843575a4d48694b46515666625657726c716f00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PHCWZMHiKFQVfbVWrlqo}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Home Address Number and Street}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PHCWZMHiKFQVfbVWrlqo}{\*\bkmkend ICG_Address2} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PGKRhqBdbxYxqpvF83Zm}{\*\bkmkstart ICG_Address3}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
00020000140000001450474b5268714264627859787170764638335a6d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PGKRhqBdbxYxqpvF83Zm}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Home Address Village}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PGKRhqBdbxYxqpvF83Zm}{\*\bkmkend ICG_Address3} }{\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 PNPTJqqg6iMJe1h6Ex8Z}{\*\bkmkstart ICG_Town}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014504e50544a71716736694d4a653168364578385a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PNPTJqqg6iMJe1h6Ex8Z}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Home Address Town}
}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PNPTJqqg6iMJe1h6Ex8Z}{\*\bkmkend ICG_Town} }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PjoqwhqJ9N9QgCTCb8Us}{\*\bkmkstart ICG_County}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 
{\*\datafield 000200001400000014506a6f717768714a394e3951674354436238557300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PjoqwhqJ9N9QgCTCb8Us}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Home Address County}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PjoqwhqJ9N9QgCTCb8Us}{\*\bkmkend ICG_County} }{\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PlMSiX7K99UZMKEX4wE3}{\*\bkmkstart ICG_Postcode}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506c4d536958374b3939555a4d4b45583477453300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PlMSiX7K99UZMKEX4wE3}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Home Address Postcode}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PlMSiX7K99UZMKEX4wE3}{\*\bkmkend ICG_Postcode} }{\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 PnJrwS5QhBQInSW3aRdf}{\*\bkmkstart ICG_Phone}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014506e4a7277533551684251496e5357336152646600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PnJrwS5QhBQInSW3aRdf}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Patient Home Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PnJrwS5QhBQInSW3aRdf}{\*\bkmkend ICG_Phone} }{\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 PTwdN4aTZBVzuE3V2wGY}{\*\bkmkstart ICG_Mobile}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014505477644e3461545a42567a754533563277475900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PTwdN4aTZBVzuE3V2wGY}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Patient Mobile Telephone}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend PTwdN4aTZBVzuE3V2wGY}{\*\bkmkend ICG_Mobile} }{\rtlch\fcs1 
\af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid15484267 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\charrsid15484267  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10043812\charrsid15484267 {\*\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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3336\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 P2BXbQcObq6JerCTmEZD}{\*\bkmkstart ICG_EmailAddress}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014503242586251634f6271364a657243546d455a4400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P2BXbQcObq6JerCTmEZD}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Patient E-mail Address}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend P2BXbQcObq6JerCTmEZD}{\*\bkmkend ICG_EmailAddress} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3342\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow3\irowband3\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \cell \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid9403445\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3455\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7018\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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 RNMvaPuv6nGxaz78v6T9}{\*\bkmkstart ICG_ReferrerName}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014524e4d7661507576366e4778617a37387636543900000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RNMvaPuv6nGxaz78v6T9}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Referring User}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend RNMvaPuv6nGxaz78v6T9}{\*\bkmkend ICG_ReferrerName} }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3338\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 FNpwPWs9rx2JXIaW7O72}{\*\bkmkstart ICG_ReferrerCode}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
000200001400000014464e7077505773397278324a58496157374f373200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname FNpwPWs9rx2JXIaW7O72}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Free Text Prompt}
}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend FNpwPWs9rx2JXIaW7O72}{\*\bkmkend ICG_ReferrerCode} }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3330\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 OdlfhakFKB5Nq7n4HAtM}{\*\bkmkstart ICG_Practice}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
0002000014000000144f646c6668616b464b42354e71376e344841744d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname OdlfhakFKB5Nq7n4HAtM}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 
Organisation National Practice Code}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend OdlfhakFKB5Nq7n4HAtM}{\*\bkmkend ICG_Practice} }{
\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3352\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3451\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx7002\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx3463\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx7034\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \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\charrsid15484267 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 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid6191006 {\*\bkmkstart ICG_Specialty}General Medicine}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx3463\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx7034\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \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\charrsid15484267 \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 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10712497 {\*\bkmkstart ICG_ClinicType}Transient Ischemic Attack}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid3228556\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3350\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx3463\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx7034\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \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\charrsid15484267 \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{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267 {\*\datafield 0000000000000000124943475f4e616d6564436c696e696369616e00000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_NamedClinician}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1459007 \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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3320\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx3463\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx7034\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx3463\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx7034\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4041\clcbpatraw23 \cellx10575\row 
}\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 P}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid14186970 rovider Department Details}{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3228556\charrsid1994260 
\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\itap2\pararsid14186970\yts18 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \f37\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid13127493 {\*\bkmkstart ICG_Provider4}AutoBook }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid13370842 -}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid13127493  York Hospital}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid14186970\charrsid15484267 
{\*\bkmkend ICG_Provider4}\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 
\af37 \ltrch\fcs0 \insrsid14186970\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14186970\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9637592\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \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 \ltrch\fcs0 
\insrsid14186970\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 \insrsid14186970\charrsid7167928 \trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid9637592\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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\charrsid15484267  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid15484267 {\*\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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267 {\*\datafield 
000000001400000005546578743100000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text1}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1459007 \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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \cell }\pard \ltrpar
\ql \li0\ri0\widctlpar\intbl\wrapdefault\nooverflow\faroman\rin0\lin0\pararsid10043812\yts18 {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid15484267 Confidential/}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 
\fs22\insrsid10043812\charrsid15484267 Silent Referral}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid15753147\charrsid15484267 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid15484267 
\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\charrsid15484267  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10043812\charrsid15484267 {\*\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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol
\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 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{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3478906\charrsid15484267 {\*\datafield 00000000000000000000000000000000000000000000
}{\*\formfield{\fftype0\fftypetxt0}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1459007 \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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3328\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\charrsid15484267  FORMDROPDOWN }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid9384172\charrsid15484267 {\*\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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3329\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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 Pd6g2N5D5WJN7HdWu23R}{\*\bkmkstart ICG_PreferredLanguage}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\datafield 
00020000140000001450643667324e354435574a4e374864577532335200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Pd6g2N5D5WJN7HdWu23R}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid2319587 Main Language}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid2319587 {\*\bkmkend Pd6g2N5D5WJN7HdWu23R}{\*\bkmkend ICG_PreferredLanguage} }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid9384172\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx3363\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6692992\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx3441\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clcbpatraw23 \cellx6991\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth3672\clpadl85\clpadb85\clpadfl3\clpadfb3\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \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\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 Non-clinical information for the booking team:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid6322439\charrsid15484267 
\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{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5579212\charrsid15484267  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid5579212\charrsid15484267 {\*\datafield 00000000000000000e4943475f41646d696e4e6f74657300000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0{\*\ffname ICG_AdminNotes}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid1459007 \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\charrsid15484267 {\*\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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\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\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 Provisional Diagnosis:}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid16334377\charrsid15484267 
\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
}{\*\bkmkstart RWeQNBGgirMh83Quhgkb}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid1530357  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid1530357 {\*\datafield 
000200001400000014525765514e42476769724d683833517568676b6200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname RWeQNBGgirMh83Quhgkb}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid1530357 Referral Reason}}}
\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid1530357 {\*\bkmkend ICG_ReferralReason}{\*\bkmkend RWeQNBGgirMh83Quhgkb} }{\rtlch\fcs1 \af37\afs22 
\ltrch\fcs0 \fs22\insrsid16334377\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid16334377\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth1\clcbpatraw8 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid6514543\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 Smoking Status}{\rtlch\fcs1 \af0\afs22 \ltrch\fcs0 \fs22\insrsid7210665\charrsid15484267 :}{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid15484267 
\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 TMYewkPgK5ZPsfYIwalz}{\*\bkmkstart ICG_SmokerCode}{\*\bkmkstart TXFX2VVBr1duv2DyEfwe}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid6563742  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid6563742 {\*\datafield 
000200001400000014544d5965776b50674b355a507366594977616c7a00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TMYewkPgK5ZPsfYIwalz}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7014476 
Single Code Entry: Smoking Status}}}\sectd \ltrsect\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid2126461\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid6563742 {\*\bkmkend TMYewkPgK5ZPsfYIwalz}  }{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid16334377\charrsid15484267 {\*\bkmkend ICG_SmokerCode}{\*\bkmkend TXFX2VVBr1duv2DyEfwe}  }{\rtlch\fcs1 \af37\afs22 \ltrch\fcs0 \fs22\insrsid10043812\charrsid15484267 \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\charrsid15484267 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts18\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 
\trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat22\cltxlrtb\clftsWidth1\clcbpatraw22 \cellx10462\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow2\irowband2\lastrow \ltrrow\ts18\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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\charrsid15484267 \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\brdrcf21 \trbrdrh
\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid2126461\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw23 \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 Referral }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15753147\charrsid1994260 Reason/}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 Letter}{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid15753147\charrsid1994260  Text}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10043812\charrsid1994260 {\*\bkmkstart ICG_ReferralNotes_S}{\*\bkmkend ICG_ReferralNotes_S}\sect }\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10043812\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10043812 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid10043812\charrsid1994260 
\par 
\par 
\par 
\par 
\par 
\par \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10043812\sftnbj \pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7210665 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid7210665\charrsid1994260 {\*\bkmkstart ICG_ReferralNotes_E}{\*\bkmkstart ICG_ClinicalData}{\*\bkmkend ICG_ReferralNotes_E}{\*\bkmkend ICG_ClinicalData}\sect }\sectd \ltrsect
\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj \pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \cf6\insrsid10712497 This part must be completed to be accepted}{\rtlch\fcs1 \af0 \ltrch\fcs0 \cf6\insrsid4072979\charrsid10712497 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 
\f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af37 \ltrch\fcs0 \b\cf6\insrsid10712497\charrsid10712497 DATE SEEN}{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\cf6\insrsid4072979\charrsid10712497 \cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid12847513 {\*\bkmkstart Text2}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497  FORMTEXT }{\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid10712497 {\*\datafield 000000001400000005546578743200000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text2}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid7567396 \u8194\'20\u8194\'20\u8194\'20\u8194
\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\bkmkend Text2}\nestcell{\nonesttables
\par }}\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth1313\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8 \cellx2015\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl 
\clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\b\cf6\insrsid10712497\charrsid10712497 DATE OF SYMPTOM ONSET}{\rtlch\fcs1 \af37 \ltrch\fcs0 \b\cf6\insrsid4072979\charrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid13794526 {\*\bkmkstart Text3}{\field{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 
{\*\datafield 000000001400000005546578743300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid10712497 \u8194\'20\u8194\'20\u8194\'20\u8194
\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid7210665\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid13794526\charrsid4532752 {\*\bkmkend Text3}\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 \insrsid13794526\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth1313\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8 \cellx2015\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12847513 {\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid4072979\charrsid4532752 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4072979\charrsid4532752 
\trowd \irow1\irowband1\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth2802\clcbpatraw23 \cellx2694\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl\brdrtbl \clbrdrb\brdrs\brdrw10\brdrcf21 
\clbrdrr\brdrtbl \clcbpat23\cltxlrtb\clftsWidth3\clwWidth7881\clcbpatraw23 \cellx10575\row }\pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid10712497 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \b0\insrsid10840098\charrsid1994260 \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj \pard\plain \ltrpar\s1\ql \li0\ri0\sb200\sl276\slmult1
\keepn\widctlpar\wrapdefault\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin0\lin0\itap0\pararsid13794526 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10712497 Description of Patient Syndrome}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid5052566 
\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3082347\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid670946 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\b\insrsid10712497\charrsid10712497 Insert last consultation
\par {\*\bkmkstart TsqQcZwQzxoL2DxA9ucT}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 {\*\datafield 
00020000140000001454737151635a77517a786f4c324478413975635400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TsqQcZwQzxoL2DxA9ucT}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 Consultations}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 {\*\bkmkend TsqQcZwQzxoL2DxA9ucT} \cell }\pard \ltrpar
\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid10712497 \trowd \irow0\irowband0\ltrrow
\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid3082347\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10 \clbrdrl\brdrnone \clbrdrb\brdrnone \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\pard \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx426\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10712497\charrsid10712497 Other relevant detail
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid10712497 {\field\flddirty{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10712497 {\*\datafield 000000001400000005546578743300000000000000000000000000}{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text3}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \lang1024\langfe1024\noproof\insrsid10712497 \u8194\'20\u8194\'20
\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497\charrsid4532752 
\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 \insrsid10712497\charrsid4532752 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow
\ts11\trgaph108\trleft5\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth3\trwWidth10485\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid10712497\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8 \cellx10490\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid670946 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid10712497 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\pard \ltrpar\ql \li0\ri0\widctlpar\intbl
\tx426\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid4018019\charrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid4018019 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\row \ltrrow}\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\pard \ltrpar\qc \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid10712497\charrsid10712497 If symptoms for more than 24hrs or patient on an anticoagulant, consider admission}{\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid10712497 
\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10683\clcbpatraw23 \cellx10575\row \ltrrow}\trowd \irow4\irowband4\ltrrow
\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\pard \ltrpar\qc \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid4018019\charrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid4018019 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 
\trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10683\clshdrawnil \cellx10575\row \ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10173\clcbpatraw23\clhidemark \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid10712497\charrsid10712497 Please confirm you have advised your patient }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\b\ul\cf6\insrsid10712497\charrsid10712497 NOT}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\cf6\insrsid10712497\charrsid10712497  to drive for one month as per DVLA driving regulations}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar
\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid10712497 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\insrsid10712497 {\*\datafield 01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 \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 \insrsid10712497 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5
\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14432043\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx489\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10173\clcbpatraw23\clhidemark \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid670946 {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid10712497 \trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth10173\clcbpatraw23\clhidemark \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb
\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \cellx10575\row \ltrrow}\trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb
\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10173\clshdrawnil \cellx9865\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth510\clshdrawnil \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 \ltrch\fcs0 
\b\cf6\insrsid4018019\charrsid10712497 \cell }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid4018019 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 
\f0\fs20\lang2057\langfe2057\langfenp2057\insrsid4018019 \trowd \irow6\irowband6\ltrrow\ts11\trgaph108\trrh-96\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \cltxlrtb\clftsWidth3\clwWidth10173\clshdrawnil \cellx9865\clvertalt\clbrdrt\brdrnone \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone 
\cltxlrtb\clftsWidth3\clwWidth510\clshdrawnil \cellx10575\row \ltrrow}\trowd \irow7\irowband7\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth5595\clcbpatraw23\clhidemark \cellx5378\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl
\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4578\clcbpatraw23 \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \cellx10575\pard \ltrpar\qj \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid10712497\charrsid10712497 As recommended by NICE please confirm you have prescribed aspirin, or that it is contr}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11237106 a}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10712497\charrsid10712497 
-indicated}{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid3817048 {\rtlch\fcs1 \af1 \ltrch\fcs0 
\insrsid10712497\charrsid10712497 Aspirin 300mg OD prescribed}{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid10712497  }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid3817048 
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid10712497 {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid10712497\charrsid10712497 Aspirin has not been prescribed because}{\rtlch\fcs1 \af1 
\ltrch\fcs0 \insrsid3817048  {\*\bkmkstart Text4}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid10712497  FORMTEXT }{\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid10712497 {\*\datafield 000000001400000005546578743400000000000000000000000000}
{\*\formfield{\fftype0\fftypetxt0\ffhps20{\*\ffname Text4}}}}}{\fldrslt {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid7567396 \u8194\'20\u8194\'20\u8194\'20\u8194\'20\u8194\'20}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af1 \ltrch\fcs0 \insrsid10712497\charrsid10712497 {\*\bkmkend Text4}\cell }\pard \ltrpar\ql \li0\ri0\sl276\slmult1
\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap2\pararsid3817048 {\field\flddirty\fldpriv{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3817048  FORMCHECKBOX }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3817048 {\*\datafield 
01000000140000000000000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 
\af37 \ltrch\fcs0 \insrsid3817048 \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 \insrsid3817048 {\*\nesttableprops\trowd \irow0\irowband0\lastrow \ltrrow\ts11\trgaph108\trleft5
\trbrdrt\brdrs\brdrw10\brdrcf21 \trbrdrl\brdrs\brdrw10\brdrcf21 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrr\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 \trbrdrv\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth4179\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid14432043\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalc\clbrdrt\brdrs\brdrw10\brdrcf21 \clbrdrl
\brdrs\brdrw10\brdrcf21 \clbrdrb\brdrs\brdrw10\brdrcf21 \clbrdrr\brdrs\brdrw10\brdrcf21 \clcbpat8\cltxlrtb\clftsWidth2\clwWidth5000\clcbpatraw8\clhidemark \cellx489\nestrow}{\nonesttables
\par }\ltrrow}\trowd \irow7\irowband7\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth5595\clcbpatraw23\clhidemark \cellx5378\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl
\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4578\clcbpatraw23 \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \cellx10575\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid670946 {\rtlch\fcs1 \af37 
\ltrch\fcs0 \insrsid10712497 \cell }\pard \ltrpar\ql \li0\ri0\sa200\sl276\slmult1\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 {\rtlch\fcs1 \af0\afs20 \ltrch\fcs0 \f0\fs20\lang2057\langfe2057\langfenp2057\insrsid7567396 
\trowd \irow7\irowband7\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10\brdrcf21 \trbrdrh\brdrs\brdrw10\brdrcf21 
\trftsWidth2\trwWidth5000\trftsWidthB3\trftsWidthA3\trautofit1\trpaddl108\trpaddt85\trpaddb85\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblrsid4018019\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt
\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth5595\clcbpatraw23\clhidemark \cellx5378\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl
\brdrs\brdrw10\brdrcf25 \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr\brdrnone \clcbpat23\cltxlrtb\clftsWidth3\clwWidth4578\clcbpatraw23 \cellx9865\clvertalt\clbrdrt\brdrs\brdrw10\brdrcf25 \clbrdrl\brdrnone \clbrdrb\brdrs\brdrw10\brdrcf25 \clbrdrr
\brdrs\brdrw10\brdrcf25 \clcbpat23\cltxlrtb\clftsWidth3\clwWidth510\clcbpatraw23\clhidemark \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 
\insrsid14942609 \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj \pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sa120\sl276\slmult1\keepn\widctlpar\brdrb
\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid3559641 \sect }\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj \pard\plain \ltrpar\s2\qj \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb
\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 \b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12532428 Generic Patient Clinical Details}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390 
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \b\insrsid12532428 {\*\bkmkstart T3KrqOhuscI2fGRF7Dvt}Patient Name}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\bkmkend T3KrqOhuscI2fGRF7Dvt}: {\*\bkmkstart PUScjdreWLX6ZIFoVwLT}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\datafield 000200001400000014505553636a647265574c58365a49466f56774c5400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname 
PUScjdreWLX6ZIFoVwLT}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Title}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid12532428 {\*\bkmkend PUScjdreWLX6ZIFoVwLT} {\*\bkmkstart P3VzlspMWEAkgU1FbC2M}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
0002000014000000145033567a6c73704d5745416b675531466243324d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P3VzlspMWEAkgU1FbC2M}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Given Name}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\bkmkend P3VzlspMWEAkgU1FbC2M} {\*\bkmkstart PxlU5fcM9KOOxFiIIhU2}}
{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\datafield 00020000140000001450786c553566634d394b4f4f784669494968553200000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PxlU5fcM9KOOxFiIIhU2}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Surname}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\bkmkend PxlU5fcM9KOOxFiIIhU2} }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8411390\charrsid1994260 \line }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid12532428 {\*\bkmkstart TGZTAXJ2TAFu2mYeZp49}Date of Birth:{\*\bkmkend TGZTAXJ2TAFu2mYeZp49} }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8411390\charrsid1994260  
{\*\bkmkstart P8GWVcfgBATAlmwfUyKC}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
0002000014000000145038475756636667424154416c6d776655794b4300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname P8GWVcfgBATAlmwfUyKC}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Date of Birth}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\bkmkend P8GWVcfgBATAlmwfUyKC} }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid8411390\charrsid1994260 \line }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid12532428\charrsid12532428 {\*\bkmkstart TERdgbdXzxryBjglBdaW}NHS Number:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid12532428 {\*\bkmkend TERdgbdXzxryBjglBdaW} 
{\*\bkmkstart PDJdvpaWYhB1BzyDBQpr}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428 {\*\datafield 
00020000140000001450444a647670615759684231427a79444251707200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname PDJdvpaWYhB1BzyDBQpr}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428 NHS Number}
}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid12532428 {\*\bkmkend PDJdvpaWYhB1BzyDBQpr} }{\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid8411390 
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Summary Problem List
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12532428 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart T9KNwqD1oVn9DPnZZVVS}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
00020000140000001454394b4e777144316f566e3944506e5a5a56565300000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T9KNwqD1oVn9DPnZZVVS}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 Problems}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428 {\*\bkmkend T9KNwqD1oVn9DPnZZVVS}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Current Repeat Medication List
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12532428 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TPsMaMslqJ532AieIxqB}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
0002000014000000145450734d614d736c714a3533324169654978714200000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TPsMaMslqJ532AieIxqB}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Medication}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 {\*\bkmkend TPsMaMslqJ532AieIxqB} 
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Allergies & Sensitivities
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12532428 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart T7zFySR4Ct5iKetnyKj8}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
00020000140000001454377a4679535234437435694b65746e794b6a3800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T7zFySR4Ct5iKetnyKj8}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 Allergies}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428 {\*\bkmkend T7zFySR4Ct5iKetnyKj8}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 Most Recent BMI
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12532428 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TqhIvmM11vIno7hd581D}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 {\*\datafield 
00020000140000001454716849766d4d313176496e6f3768643538314400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TqhIvmM11vIno7hd581D}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12532428 BMI}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428\charrsid12532428 {\*\bkmkend TqhIvmM11vIno7hd581D}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 Most Recent Blood Pressure}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12532428 
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TT4Y8kzsi1aPx2OJxRuv}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3817048  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3817048 {\*\datafield 
00020000140000001454543459386b7a736931615078324f4a7852757600000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TT4Y8kzsi1aPx2OJxRuv}}}}}{\fldrslt {\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid3817048 Blood Pressure}}}
\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\bkmkend TT4Y8kzsi1aPx2OJxRuv}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 Smoking Status
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 
{\*\bkmkstart TV95FDOPStfxr8vGynn7}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\insrsid3817048  FORMTEXT }{\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\insrsid3817048 {\*\datafield 
0002000014000000145456393546444f505374667872387647796e6e3700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TV95FDOPStfxr8vGynn7}}}}}{\fldrslt {\rtlch\fcs1 \af37\afs20 \ltrch\fcs0 \fs20\insrsid3817048 S
ingle Code Entry: Smoking Status}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
{\*\bkmkend TV95FDOPStfxr8vGynn7}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 Alcohol Intake
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid3817048 \~{\*\bkmkstart Tbsih4z3UqhWL3k6m1NH}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af37 \ltrch\fcs0 \f31506\insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af37 \ltrch\fcs0 
\f31506\insrsid3817048\charrsid3817048 {\*\datafield 0002000014000000145462736968347a33557168574c336b366d314e4800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tbsih4z3UqhWL3k6m1NH}}}}}{\fldrslt {\rtlch\fcs1 \af37 
\ltrch\fcs0 \f31506\insrsid3817048\charrsid3817048 Single Code Entry: Alcohol consumption}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af37 
\ltrch\fcs0 \f31506\insrsid3817048\charrsid3817048 {\*\bkmkend Tbsih4z3UqhWL3k6m1NH}
\par }\pard\plain \ltrpar\s2\ql \li0\ri0\sb200\sl276\slmult1\keepn\widctlpar\brdrb\brdrs\brdrw10\brsp20 \wrapdefault\aspalpha\aspnum\faauto\outlinelevel1\adjustright\rin0\lin0\itap0\pararsid3817048 \rtlch\fcs1 \ab\af0\afs28\alang1025 \ltrch\fcs0 
\b\f37\fs28\lang2057\langfe1033\kerning32\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7567396 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 Investigations}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7865300\charrsid1994260 
\par }\pard\plain \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid1994260 \rtlch\fcs1 \af0\afs22\alang1025 \ltrch\fcs0 \f37\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\rtlch\fcs1 
\af0 \ltrch\fcs0 \b\ul\insrsid3817048\charrsid3817048 FBC
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid7865300\charrsid4551612 Hb:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4551612  {\*\bkmkstart TBmn5lPVDBkKjpMnSbVm}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1459007  FORMTEXT }{\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid1459007 {\*\datafield 00020000140000001454426d6e356c505644426b4b6a704d6e5362566d00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TBmn5lPVDBkKjpMnSbVm}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid7014476 Single Code Entry: Haemoglobin estimation}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 
{\*\bkmkend TBmn5lPVDBkKjpMnSbVm}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048\charrsid3817048 Platelets:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  {\*\bkmkstart TCUWd3nMmzrtEv9EGm7p}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
 FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 0002000014000000145443555764336e4d6d7a727445763945476d377000000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TCUWd3nMmzrtEv9EGm7p}}}}
}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 Single Code Entry: Platelet count}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7865300 {\*\bkmkend TCUWd3nMmzrtEv9EGm7p}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048\charrsid3817048 WCC:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  {\*\bkmkstart T7TbBwJ2qqVWHeSpUw4p}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }
{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 0002000014000000145437546242774a3271715657486553705577347000000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname T7TbBwJ2qqVWHeSpUw4p}}}}}{\fldrslt 
{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 Single Code Entry: Total white cell count}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {
\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 {\*\bkmkend T7TbBwJ2qqVWHeSpUw4p}
\par 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\ul\insrsid3817048\charrsid3817048 LFTs}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\ul\insrsid3817048 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048 Bilirubin: {\*\bkmkstart Tqs1djBWmQxSxBWX8jiQ}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3817048\charrsid3817048 {\*\datafield 00020000140000001454717331646a42576d51785378425758386a695100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tqs1djBWmQxSxBWX8jiQ}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3817048\charrsid3817048 Single Code Entry: Serum bilirubin level}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid3817048 {\*\bkmkend Tqs1djBWmQxSxBWX8jiQ}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048\charrsid3817048 ALT:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  {\*\bkmkstart TQu3OhnHn8f377QkkPax}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }
{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 000200001400000014545175334f686e486e3866333737516b6b50617800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TQu3OhnHn8f377QkkPax}}}}}{\fldrslt 
{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 Single Code Entry: Serum alanine aminotransferase level}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048 {\*\bkmkend TQu3OhnHn8f377QkkPax}
\par ALP: {\*\bkmkstart TH4VEXQh3YYIeFnoiBeA}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 
00020000140000001454483456455851683359594965466e6f6942654100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TH4VEXQh3YYIeFnoiBeA}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
Single Code Entry: Total alkaline phosphatase}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 
{\*\bkmkend TH4VEXQh3YYIeFnoiBeA}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048\charrsid3817048 Total Protein:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  {\*\bkmkstart TvXQhnxMI7BmAFiyU1uo}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
 FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 00020000140000001454765851686e784d4937426d414669795531756f00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TvXQhnxMI7BmAFiyU1uo}}}}
}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 Single Code Entry: Serum total protein}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048 {\*\bkmkend TvXQhnxMI7BmAFiyU1uo}
\par Albumin: {\*\bkmkstart TVQryVuAo6dLjLM7jmrq}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 
00020000140000001454565172795675416f36644c6a4c4d376a6d727100000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TVQryVuAo6dLjLM7jmrq}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
Single Code Entry: Serum albumin}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048 
{\*\bkmkend TVQryVuAo6dLjLM7jmrq}
\par 
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\ul\insrsid3817048\charrsid3817048 U+Es
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid7865300\charrsid4551612 CRP:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4551612  {\*\bkmkstart TQJSRxLlyG8xrb7qNCOd}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1459007  FORMTEXT }{\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid1459007 {\*\datafield 00020000140000001454514a5352784c6c79473878726237714e434f6400000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TQJSRxLlyG8xrb7qNCOd}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid7014476 Single Code Entry: Serum C reactive protein level}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 
\insrsid7865300 {\*\bkmkend TQJSRxLlyG8xrb7qNCOd}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid13240665\charrsid13240665 ESR:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid13240665  }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid13240665 \~{\*\bkmkstart Tgdc14ILEvrUhZO5Vyif}}{\field\fldedit{\*\fldinst {
\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid13240665  FORMTEXT }{\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid13240665 {\*\datafield 000200001400000014546764633134494c45767255685a4f355679696600000000000000000000000000}
{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname Tgdc14ILEvrUhZO5Vyif}}}}}{\fldrslt {\rtlch\fcs1 \af0\afs24 \ltrch\fcs0 \f0\fs24\insrsid13240665 Single Code Entry: Erythrocyte sedimentation rate}}}\sectd \ltrsect
\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid13240665\charrsid13240665 {\*\bkmkend Tgdc14ILEvrUhZO5Vyif}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid7865300\charrsid4551612 T}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048 otal Cholesterol}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid7865300\charrsid4551612 :}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  
{\*\bkmkstart TNTxDSFWhkcYI9jX3nBO}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 
000200001400000014544e547844534657686b635949396a58336e424f00000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TNTxDSFWhkcYI9jX3nBO}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid13502591 
Single Code Entry: Total cholesterol:HDL ratio...}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7865300 
{\*\bkmkend TNTxDSFWhkcYI9jX3nBO}
\par }{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid7865300\charrsid4551612 HbA1c:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid4551612  {\*\bkmkstart TbMwgudE3NLJ7nUSHhQx}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1459007  FORMTEXT }{\rtlch\fcs1 
\af0 \ltrch\fcs0 \insrsid1459007 {\*\datafield 00020000140000001454624d7767756445334e4c4a376e55534868517800000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TbMwgudE3NLJ7nUSHhQx}}}}}{\fldrslt {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid7014476 Single Code Entry: Haemoglobin A1c level - IFCC standardised}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 
\ltrch\fcs0 \insrsid7865300 {\*\bkmkend TbMwgudE3NLJ7nUSHhQx}
\par }\pard \ltrpar\ql \li0\ri0\sl276\slmult1\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7167928 {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048\charrsid3817048 TSH:}{\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid3817048  
{\*\bkmkstart TPj2Izvi4ivWKax1aCgw}}{\field\fldedit{\*\fldinst {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048  FORMTEXT }{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 {\*\datafield 
00020000140000001454506a32497a7669346976574b6178316143677700000000000000000000000000}{\*\formfield{\fftype0\ffprot\fftypetxt0\ffhps20{\*\ffname TPj2Izvi4ivWKax1aCgw}}}}}{\fldrslt {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid3817048\charrsid3817048 
Single Code Entry: Serum TSH level}}}\sectd \ltrsect\margtsxn720\psz9\sbknone\linex0\headery340\footery340\endnhere\sectunlocked1\pgbrdropt32\sectdefaultcl\sectrsid10840098\sftnbj {\rtlch\fcs1 \af0 \ltrch\fcs0 \b\insrsid12596147\charrsid3817048 
{\*\bkmkend TPj2Izvi4ivWKax1aCgw}
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid12596147 
\par 
\par 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid10243840 
\par }{\rtlch\fcs1 \af37 \ltrch\fcs0 \insrsid660593 
\par }{\*\themedata 504b030414000600080000002100e9de0fbfff0000001c020000130000005b436f6e74656e745f54797065735d2e786d6cac91cb4ec3301045f748fc83e52d4a

00000021000dd1909fb60000001b0100002700000000000000000000000000b20900007468656d652f7468656d652f5f72656c732f7468656d654d616e616765722e786d6c2e72656c73504b050600000000050005005d010000ad0a00000000}
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617020786d6c6e733a613d22687474703a2f2f736368656d61732e6f70656e786d6c666f726d6174732e6f72672f64726177696e676d6c2f323030362f6d6169
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