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<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0//EN" "http://www.w3.org/TR/REC-html40/strict.dtd">
<html>
<head>
  <meta name="qrichtext" content="1" />
  <meta http-equiv="Content-Type" content="text/html; charset=UTF-8" />
  <style type="text/css">
    p, li { white-space: pre-wrap; }
  </style>
</head>
<body style=" font-family:'Lucida Grande'; font-size:13pt; font-weight:400; font-style:normal;">
<table border="1" style=" margin-top:0px; margin-bottom:0px; margin-left:0px; margin-right:0px;" width="100%" cellspacing="0" cellpadding="0">
<tr>
<td width="33%">
<p align="center"><span style=" font-size:14pt; font-weight:600;">[[USERTITLE] ][[USERFULLNAME]</span></p>
<p align="center">]</span></p>
<p align="center">[[USERSPECIALITIES]</p>
<p align="center">][[USERQUALIFICATIONS]][</p>
<p align="center"><span style=" font-size:10pt;">[USERIDENTIFIANTS]</span>]</p>
<p align="center">[__________</p>
<p align="center">[USERFULLADRESS]</p>
<p align="center">][[USERFULLCONTACT]]</p>
</td>
<td width="33%">
<p align="center">[[DOCUMENTTITLE]]</p></td>
<td width="33%">
<p>[[DATE]][</p>
<p style="-qt-paragraph-type:empty; margin-top:0px; margin-bottom:0px; margin-left:0px; margin-right:0px; -qt-block-indent:0; text-indent:0px;"></p>
<p>[PATIENTFULLNAME]]</p>
</td>
</tr>
</table>
<p style="-qt-paragraph-type:empty; margin-top:0px; margin-bottom:0px; margin-left:0px; margin-right:0px; -qt-block-indent:0; text-indent:0px;"></p>
<p style="-qt-paragraph-type:empty; margin-top:0px; margin-bottom:0px; margin-left:0px; margin-right:0px; -qt-block-indent:0; text-indent:0px;"></p>
</body>
</html>