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				&nbsp;</td>
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				<span style="font-size: large;"><strong><span class="field">a</span> <span class="field">b</span> <span class="field">c</span> - <span class="field">aze</span> ans<br />
				N&eacute;<span class="field">e</span> <span class="field">a</span>&nbsp; le <span class="field">28/05/1958</span> </strong></span></td>
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<table border="0" cellpadding="1" cellspacing="1" style="height: 274px; width: 100%;">
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			<td style="vertical-align: top; width: 45%;">
				<font class="Apple-style-span" size="3">aze aze aze aze aze aze aze&nbsp;</font><br />
				&nbsp;</td>
			<td style="width: 30%;">
				&nbsp;</td>
			<td style="vertical-align: top; width: 25%;">
				<span style="font-size: medium;">Examens :<br />
				<br />
				Arriv&eacute;e : </span><br />
				<br />
				<span style="font-size: medium;">PEC :</span></td>
		</tr>
		<tr>
			<td>
				<span style="font-size: medium;">T&eacute;l. domicile&nbsp; :&nbsp; <span class="field">aze aze aze zae&nbsp;</span><br />
				T&eacute;l. bureau&nbsp;&nbsp;&nbsp;&nbsp; :<br />
				Portable&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; :&nbsp; </span><br />
				&nbsp;</td>
			<td colspan="2" rowspan="1" style="vertical-align: top;">
				<span style="font-size: medium;">Profession :</span></td>
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			<td>
				<span style="font-size: medium;">N&deg; SS : </span><br />
				&nbsp;</td>
			<td colspan="2" style="vertical-align: top;">
				<span style="font-size: medium;">Nom et pr&eacute;nom de l&#39;assur&eacute; :</span></td>
		</tr>
		<tr>
			<td>
				<span style="font-size: medium;">Date AT : </span><br />
				&nbsp;</td>
			<td colspan="2" style="vertical-align: top;">
				<span style="font-size: medium;">Employeur : </span></td>
		</tr>
		<tr>
			<td>
				<span style="font-size: medium;">Caisse :</span><br />
				&nbsp;</td>
			<td colspan="2" style="vertical-align: top;">
				<span style="font-size: medium;">Mutuelle :</span></td>
		</tr>
		<tr>
			<td colspan="3">
				<span style="font-size: medium;">M&eacute;decin traitant : Dr </span></td>
		</tr>
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