ࡱ> s bjbj2)2) 9PCfPCf  8X+ltdR!h! t!l+n+n+n+n+n+n+$Y.1p+|!< !@|!|!+d+"""|!^l+"|!l+""V)@*0#Y$U!0* X++0+<*T2h"^2**2*|!|!"|!|!|!|!|!++"|!|!|!+|!|!|!|!2|!|!|!|!|!|!|!|!|! X N:  CLINICAL QUERY PROFORMA FOR PAEDIATRIC NEUROLOGY URGENT ADMISSION / ADVICE ONLY In order to discuss a patient with the on call team, please complete this form in its entirety and email it to  HYPERLINK "mailto:gos-tr.neuro-referrals@nhs.net" gos-tr.neuro-referrals@nhs.net. Upon receipt of the completed form, the on call team will contact you regarding the query on the contact number provided. Please note - For information governance, this form must be sent using an nhs.net account. Are you calling for routine outpatient review? YES Send referral letter to  HYPERLINK "mailto:gos-tr.neuroreferrals@nhs.net" gos-tr.neuro-referrals@nhs.net  NO Are you calling for review of neuroimaging only? YES Send referral letter to the Consultant Paediatric Neuroradiologists NO Are you calling out of hours (outside 9am-4pm)? YES Complete this form and email it to  HYPERLINK "mailto:gos-tr.neuro-referrals@nhs.net" gos-tr.neuro-referrals@nhs.net from an nhs.net account, call GOSH switchboard (0207 405 9200) and ask to speak to the on-call neurology SpR NO Are you calling within hours (9am-4pm) YES Please complete this form and email it to  HYPERLINK "mailto:gos-tr.neuroreferrals@nhs.net" gos-tr.neuro-referrals@nhs.net from an nhs.net account, and the on call consultant will call you back between 1-2pm PATIENT PERSONAL AND GP DETAILSDate referral made: Name of referring hospital:GOSH MRN number (if known):NHS Number: Name:Date of Birth:Male  FORMCHECKBOX  Female  FORMCHECKBOX Patients home address and telephone: GP Name, practice address and telephone number Where is the patient now? Please state: Home or name of hospital/ward, contact telephone, etc. * REFERRING CLINICIAN CONTACT DETAILSName of referring consultant:Job title:Email address: @nhs.netBleep number:Telephone number:* REASON FOR REFERRALWhat is the present clinical question or concern? If unsure please clarify with your consultant * EXAMINATIONInclude recent GCS, HR, RR, Sats, Temp * CURRENT MEDICATIONS Include doses and times of any rescue medications given * CURRENT NEUROLOGICAL PROBLEMPlease include history, differential diagnosis plus other medical history and relevant co-morbidities. * RELEVANT INVESTIGATIONS -All Neuroimaging scans and reports should be sent in advance to GOSH via IEP at time of referral. Types, dates and brief conclusions of imaging: Lumbar Puncture(s): EMG/Nerve Conduction Studies : Other Investigations (e.g. blood tests, microbiology):  Many thanks for completing this form      23CDEFQRSͱͱ|dM5/h->ho 5CJOJPJQJ^JaJnH tH ,h->h CJOJPJQJ^JaJnH tH .ho CJOJPJQJ^JaJmH nH sH tH 7h{ho 5CJ$OJPJQJ^JaJ$mH nH sH tH 1heJ5CJ$OJPJQJ^JaJ$mH nH sH tH 7h{h{5CJ$OJPJQJ^JaJ$mH nH sH tH 1h 5CJ$OJPJQJ^JaJ$mH nH sH tH 1ho 5CJOJPJQJ^JaJmH nH sH tH RS    # % }dddd$d$If]^a$gd9A$d$Ifa$gd9A$;d]^;a$gd{9$$;d$d%d&d'd@&NOPQ]^;a$gd$($;d@&]^;gd$( $d@&gd$(    ϸϸjjVA)hi 5CJOJPJQJ^JaJnH tH &hi CJOJPJQJ^JaJnH tH 3h->h 0J5CJOJPJQJ^JaJnH tH 8jh->h 5CJOJPJQJU^JaJnH tH ,h->h CJOJPJQJ^JaJnH tH ,h->h]CJOJPJQJ^JaJnH tH /h->h]5CJOJPJQJ^JaJnH tH /h->h 5CJOJPJQJ^JaJnH tH     # $ % f ϺzzfffF.z/h9Ah->5CJOJPJQJ^JaJnH tH ?jh9Ah+R5CJOJPJQJU^JaJmHnHtH u'h9Ah+R5CJOJPJQJ^JaJ,h9Ah->CJOJPJQJ^JaJnH tH !hy-5OJPJQJ^JnH tH /h->ho 5CJOJPJQJ^JaJnH tH )hi 5CJOJPJQJ^JaJnH tH /h->hGD5CJOJPJQJ^JaJnH tH /h->hi 5CJOJPJQJ^JaJnH tH  f g 䴞͊kWWC,,h9Ah+RCJOJPJQJ^JaJnH tH 'h9Ah->5CJOJPJQJ^JaJ'h9Ah+R5CJOJPJQJ^JaJ<jh9Ah+RCJOJPJQJU^JaJmHnHtH u'h9Ah->5OJPJQJ^JnH tH *hx{0JCJOJPJQJ^JaJnH tH 0h9Ah->0JCJOJPJQJ^JaJnH tH ,h9Ah->CJOJPJQJ^JaJnH tH 5jh9Ah->CJOJPJQJU^JaJnH tH % I000$d$If]^a$gd9Akd$$Ifl{F;fp#+R t05&6    44 lapyt9A$d$If]a$gd9A 2kd$$IflF;fp#+R t05&6    44 lapyt9A$d$If]a$gd9A$9d$If]9^a$gd9A  D E F G J K L M N k ~  tUt<jh9Ah+RCJOJPJQJU^JaJmHnHtH u'h9Ah+R5OJPJQJ^JnH tH /h9Ah+R5CJOJPJQJ^JaJnH tH ?jh9Ah+R5CJOJPJQJU^JaJmHnHtH u'h9Ah+R5CJOJPJQJ^JaJ,h9Ah+RCJOJPJQJ^JaJnH tH 'h9Ah->5OJPJQJ^JnH tH   D $d$If]a$gd9A$d$If]^a$gd9A$d$Ifa$gd9AD E G J K ^EE7d$Ifgd9A$d$If]^a$gd9Akd$$IflF;fp#+R t05&6    44 lapyt9AK L M N 2kd$$IflF;fp#+R t05&6    44 lapyt9A$d$If]a$gd9A$9d$If]9^a$gd9AN k ~  m $d$If]a$gd9A$d$If]^a$gd9A$d$Ifa$gd9A m n o p s t u v w Ӽ猌xYEExEEE'h9Ah+R5CJOJPJQJ^JaJ<jh9Ah+RCJOJPJQJU^JaJmHnHtH u'h9Ah+R5OJPJQJ^JnH tH ,h9Ah+RCJOJPJQJ^JaJnH tH 0h3FMhg 0JCJOJPJQJ^JaJnH tH ,hg hg CJOJPJQJ^JaJnH tH &hg CJOJPJQJ^JaJnH tH /jhg CJOJPJQJU^JaJnH tH m n p s t `GG6$d$Ifa$gd9A$d$If]^a$gd9Akd$$IflF;fp#+R t05&6    44 lapyt9At u v w 2kd$$IflF;fp#+R t05&6    44 lapyt9A$d$If]a$gd9A$9d$If]9^a$gd9Aw { $d$If]a$gd9A$d$If]^a$gd9A$d$Ifa$gd9A     # $ { | } ~ ǰ|f|RA,)ho 5CJOJPJQJ^JaJnH tH !hy-5OJPJQJ^JnH tH 'h9Ah+R5OJPJQJ^JnH tH *hg 0JCJOJPJQJ^JaJnH tH 0h9Ah+R0JCJOJPJQJ^JaJnH tH 5jh9Ah+RCJOJPJQJU^JaJnH tH ,h9Ah+RCJOJPJQJ^JaJnH tH /h9Ah+R5CJOJPJQJ^JaJnH tH ?jh9Ah+R5CJOJPJQJU^JaJmHnHtH u{ | } ~ `KA4 d<<$If $da$$;d]^;a$gd{kd$$IflF;fp#+R t05&6    44 lapyt9A~   !"0̵㞵̵㵵ya/h->hJJ5CJOJPJQJ^JaJnH tH 8jh->hJJ5CJOJPJQJU^JaJnH tH hJJh ,h->h CJOJPJQJ^JaJnH tH ,h->hJJCJOJPJQJ^JaJnH tH ,h->ho CJOJPJQJ^JaJnH tH ho /h->ho 5CJOJPJQJ^JaJnH tH  |l|d<<$Ifgd d<<$Ifukdg$$Ifl;p#5&  &05&44 lap &yt-> sfff d<<$Ifkd $$IflF; p#   05&    44 layt-> scd<<$Ifgd kd$$IflF; p#   05&    44 layt-> #fkdL $$Ifl;p#5&05&44 layt->d<<$Ifgd fkd$$Ifl;p#5&05&44 layt->  vd<<$IfgdJJikd $$Ifl4;p#5&05&44 laf4yt->d<<$Ifgd ]^ ikd $$Ifl4;p#5&05&44 laf4yt-> d<<$Ifikdh $$Ifl4;p#5&05&44 laf4yt->012DKLZ[\]^ëëtÔpYE1EE&h]CJOJPJQJ^JaJnH tH &hi CJOJPJQJ^JaJnH tH ,hi ho CJOJPJQJ^JaJnH tH hJJ>jf h->hJJ5CJOJPJQJU^JaJnH tH ,h->hJJCJOJPJQJ^JaJnH tH /h->hJJ5CJOJPJQJ^JaJnH tH 8jh->hJJ5CJOJPJQJU^JaJnH tH >j h->hJJ5CJOJPJQJU^JaJnH tH ^zzz d<<$IfhkdX $$Ifl;p#5&05&44 layt->d<<$Ifgdi EFdepqѺ鋋t`IEIEIhJJ,hi hJJCJOJPJQJ^JaJnH tH 'h)ho 5OJPJQJ^JnH tH ,hi h CJOJPJQJ^JaJnH tH /hi hi 6CJOJPJQJ^JaJnH tH ,hi ho CJOJPJQJ^JaJnH tH ,hi h]CJOJPJQJ^JaJnH tH &hi CJOJPJQJ^JaJnH tH ho ,hi hi CJOJPJQJ^JaJnH tH zzz d<<$Ifd<<$Ifgdi hkd $$Ifl;p#5&05&44 layt->E d<<$Ifhkdv $$Ifl;p#5&05&44 layt->EFdyd<<$IfgdJJukd $$Ifl;p#5&  &05&44 lap &yt->depq#fkdA$$Ifl;p#5&05&44 layt->d<<$IfgdJJfkd$$Ifl;p#5&05&44 layt->CPopqr龺ziXB/$h)h]OJPJQJ^JnH tH +hi hi 6CJOJPJQJ^JnH tH !hJJ6CJOJPJQJ^JaJ!hi 6CJOJPJQJ^JaJ'hi hi 6CJOJPJQJ^JaJ/hi hi 6CJOJPJQJ^JaJnH tH 'h)hJJ5OJPJQJ^JnH tH hJJ,hi hJJCJOJPJQJ^JaJnH tH &hi CJOJPJQJ^JaJnH tH ,hi hGDCJOJPJQJ^JaJnH tH qfkd$$Ifl;p#5&05&44 layt->d<<$IfgdJJ#fkd$$Ifl;p#5&05&44 layt->d<<$IfgdJJfkde$$Ifl;p#5&05&44 layt->pqrstuvwyukd{$$Ifl;p#5&  &05&44 lap &yt->d<<$IfgdJJ rstuvwxmWDD1$h)hi OJPJQJ^JnH tH $h]hi OJPJQJ^JnH tH +h]hi 6CJOJPJQJ^JnH tH %hi 6CJOJPJQJ^JnH tH hi 'h)hi 5OJPJQJ^JnH tH !hi 5OJPJQJ^JnH tH hJJ$h)hJJOJPJQJ^JnH tH hOJPJQJ^JnH tH hi OJPJQJ^JnH tH hk:OJPJQJ^JnH tH hJJOJPJQJ^JnH tH wxd<<$Ifgdi hkd$$Ifl';p#5&05&44 layt->tdddddddd<<$Ifgdi $d<<$Ifa$gdi wkd$$Ifl;p#5&  &05&44 lap &yti      ,-rĮxd`J7J%h6CJOJPJQJ^JnH tH +h]hJJ6CJOJPJQJ^JnH tH hJJ'h)hJJ5OJPJQJ^JnH tH $h)hi OJPJQJ^JnH tH hi OJPJQJ^JnH tH $h]hi OJPJQJ^JnH tH +h]hi 6CJOJPJQJ^JnH tH %hi 6CJOJPJQJ^JnH tH !hi 5OJPJQJ^JnH tH 'h)hi 5OJPJQJ^JnH tH hi d<<$Ifgdi hkd#$$Ifl';p#5&05&44 layt->    tddddddd<<$Ifgdi $d<<$Ifa$gdi wkd$$Iflx;p#5&  &05&44 lap &yti   ,d<<$IfgdJJhkd6$$Ifl';p#5&05&44 layt->,-vfffffffffd<<$IfgdJJ$d<<$Ifa$gdJJukd$$Ifl;p#5&  &05&44 lap &yt-> ͺݪtp\FBh]+h]h]6CJOJPJQJ^JnH tH 'h)h]5OJPJQJ^JnH tH hJJ$h)hi OJPJQJ^JnH tH $h]hOJPJQJ^JnH tH h]OJPJQJ^JnH tH hOJPJQJ^JnH tH $h]hi OJPJQJ^JnH tH hi OJPJQJ^JnH tH hJJOJPJQJ^JnH tH $h]hJJOJPJQJ^JnH tH t$d<<$Ifa$gdJJhkdE$$Ifl;p#5&05&44 layt->d<<$IfgdJJ#$STUVWnopttddddddddd<<$Ifgd]$d<$Ifa$gd]wkd$$Ifl;p#5&  05&44 lap yt->  "#$STUVWmnopqrҿwwwcRRRA!h5OJPJQJ^JnH tH !h]5OJPJQJ^JnH tH 'h)h5OJPJQJ^JnH tH !h]5OJPJQJ^JnH tH 'h)h]5OJPJQJ^JnH tH $h)hOJPJQJ^JnH tH h]OJPJQJ^JnH tH $h)h]OJPJQJ^JnH tH )h]6CJOJPJQJ^JaJnH tH /hJJh]6CJOJPJQJ^JaJnH tH pqrthkdX$$Ifl;p#5&05&44 layt->$d<<$Ifa$gdJJd<<$Ifgd]      ÿuqmhS%h{jh EUmHnHtH ujh EUmHnHuh Eh0I}jh0I}Uh&hCJOJPJQJ^JaJnH tH ho h]+h]h6CJOJPJQJ^JnH tH %h6CJOJPJQJ^JnH tH %h]6CJOJPJQJ^JnH tH      Gr gd E r d$t;d]t^;a$gd5 01h:pi . A!"#$% nGF}? =Ά PNG  IHDRLLsRGBgAMA a pHYs&?G{IDATx^WDPc~јhb%hk"]PP)*Rz/K{ oνn=s;3gΙ#r@[ڕ+7ǣʍ=22Pq<9h2k,ض#(G9G`;_L[!i?VbZ؁8XbSILRn{OynXy /3Qr.Y3[=]bZW0 SF f~}D8c;KnrB#_v(=.fY#KaĴ@8F1CLIWU5v`,#?(G9Q>:\+g\]5 j,`0]Tl#/U\Qr|Seb^fj]e]F|Qr|dSd޶,)8AnoΪJql8(Grf%% 9x3ݾl6ϑH0s͔x3ĥHѹabL۳II^"U&L4q{|:r# Ț5噧{L| yd `>|ФKZl_G#PRS54q3fH͚5wF2tuB~˕-7ԑV˗9rI&smErYgIR.111ңGw.cRVxy~[Oׯ/6nߤr*'ʿ?.j`9x3>U2Eڷkg:)%K:m89rW%JQ[^ه/Ǐ3ɚXu#t Or,z6nƖ}<8$;wy?)Hjq 35a*uUN-]td/#A;vy>[23ٓm:3'KZZqs~`x;\t;Ysgf bE۳aì>y?̃7?˹[M:u9biɒf~./[@ww=$<\wrޟd,vEoef>0P0 9~\ #0'. `J~EñJ*8,s^ӻ̢ٳgK4iРԫ[W~mT$;v= ,0o i5}ҩSGwFaÆɠA믗s9Ǥ Y >\ (+WUV&y߿;kLi޼|SS|uժ?Qn&TF}_\nHݺ P<,ǻkN3f$''IÆ?0?t^/^lXal,CZf) 2D4nlcc[˲enLj+WHZjԫWWԯ/]:w6[ OiFճSC#&Md@7̊+L~}O&C2ct G}xÜ\ TW0̔rnێRexYN@~i8Q90i H-s߾\LSd} C۶%_l]zYLby@(22/V-[;w&n7qE,ļ{sq8roF-/o{ K/ē-+u瞻ey6aÆ_.gyf\=G 6T[hz嗵\Tո]yKmۘp͛5/%N[U??<]A.2)G&Z\1XGd^X%W'>`ۚ%%0ɋOJG2ڨi/o'O";s,Dp)YpZj=tWdر,8LC;OɕW\!5FsOG%yq;geH~gIIIցaH?֯'|'N~ɳQ/XN &]YFn%m#rq袋TShX |?gȵ\cuY䟸G@:%9Y/kJڵmk['.+`ɕkmE$nBi9ja$')p*'jm&(ݗ3!4G~(r 7;" 0˗+k:xroF_<0շo_ǒy0Mn3Ι"}`K3f̐Ӕ8:`+ 0a&ѣGˬYvѴxj[F6o;>;QW?|92QKVd_M;L䟑aʜ*.8ʏ6\ع@[, Βm۸;Ol.FEȖN4̓$.[o4jT̔Z1ԟgrB3֟]eߐ_g Ė"D&NTlܨy~cEgqu" /`ґ0ׯ_g" En+ ٚ@ RdY&foWMCepH 4H~Q Zb RN3 pS3LʩfںDgϟ77eH};hS?jZN8#h"Ype E*azW/h_T3hAQbLX䣱'0qug)MY`dXY[ț#4|R5WTM3U4ja=efoLy_71nIVM㤃96m|0AˉmŊ)2 @1%ozH,l&2C1F)r CJ*of%DN'O~tw&Mh0"w&L3ڸ9¯P/a~Uʕ#gd2;V Fh:viZU\ٲ&ݮPnL:yYvO\.v srrI2OT)*H&(' ^<=pLٴO64fyblʿHLTAJ4cN'x5L+kwFaz9` ^pq5sѿK CL'=ݸ9?;o3MA9G0̀P^?!/`SJ p?\]|!ѭr["o0ge ؈Ã`vlIrrrnݺrUW <(;dN>CeŮag#渂fݴev:yi X9È`&Gɸ5#!g)IAji 8YmKICesvqlE#?Ϙ! I1isI0,Zbyҩ0/!IN7Mfpaْ{ҧ՝iod3 rZ5l({vt062?^+K~{`%?1b1>kSԩYrZĴGwԒO\.E$eWГS:Ё1;[.Zgb_K2>Ȅn*hw-ci:k6C~"9sds6ٶg/N 9jۅwS}򦩸8/`>%s*RˌL_~6f6 ( 3踜VUtib+ ~q\G;`9Z5kR0Ln2q'bnd՞yFa4=_|I71׵Ap-0En-%&*p'SH'+wHK$f]]{liَ-RvLe|uoD:חʟ˳ceE!J[0FNZVNO"g@Hc>2E _~ Av L2%}w]&@ K;u2ڞC# 2HVXpۍ٦☢t<}[n5Js߻wf:lObNoTSd~ p \%"^NYByua )?hYg[vwM8S7~qCܹs89M%U"˱[WaÆf:iօ0*2 zßcw4d['60(vo Tl5Z~o2B{-_@Kf ר!a~%)(&V))`٬!Fkǂ8&\ܱۺOӡ3TJD5S"lbfo& UtNnxAlIݫ9j,oJCdñ!MNN6y ^HH3~m\O)$_L̄!Y=+퍧`fp']:w2i>I7橋5]]^к[L9j:oV-yN֮]cٕ֭NBBS9uG gJ%X>n_ D\\¦wѺ`J Et#0n0Gs&g !ں'Wl͖I`eХ mmRZI ~%ǜ ܲ]NJa*v݈kɿٽgCAteUrj}` ͵Эlw[oe?*?GQQ{PQ{O~Ox~T[ATP'3??C^?RQAO|LKvH>Kv9 0Y 2sU\/F|e~Re3?i>> 1@+X:6>_:e';s;~#?Hv٧fB䜴bjs9[AVpLҿXnK7/hfy|O7w+[:p`#ש6y*?ksqO1D9Q>"r(I0oaZV?ӕ8&K 2msQWD`Kqn_liwN4GNS EX) 2yf@,~G9Q>^9"s嚮$at`a*`gg~3od!:Q5=5l[lZ ~Lfэݿ=[( 6e_ھ@dyfH~/,`0|#_yCF|̅4?_|8ُȯs6[3$\`hI]JB69aZwg+ #M5rw|j''&kD9~Tc#?Q>ُsLr~ ^.`ƍKL}wYsN24cJi滿"oOP. |,"P3Y& lG{e^mdȐm /\5jTR{"OA,f?l[7k6lڸ9.?oHs1cAcQnbj⎋<:C-+H%]fy\7yt=/-JJ*[ B1jr NapT/_ke^Щ Of$Arcyt ƚv=/7wCj~~ b1gI'c8:ic~ac|wJ=W<9s??8YK^!Zfl?nY_.9ʑOڣ9a/FV 2݌LlKTq=Tno9]yyxqՄyRY-߱QZ.Q_NM |aX0-˦r9 G8s <`Od{[3BO&\/m95Ӯ];sܼ 7qйo0b뎠:vG{{[ut~};xW3b9kIbN2QgXq-D~\D-7TdWn4Po?HeDEg,o6FiY># hcvip<78AmWM\6p K_;TFwAG J㥂v7Q2 }=gr1Eʕ AxXd̙75zYSaO^rM衇& Cۓ>iѼ)7408o̓1?."`&v$Y \"#mkR-TM>v]%Onɱ6lN{Yi* oJ$47 >/w /}Ö \y34d̉ .`?.FigE!B~OE hMEN.j7ޢ8Y"fa_RRVDE[ܽi?Ř.udu15[RkJ65d?~/'u!^5MI0'}NSYst%/`ijw]pcǎaÆ<ES =~՚4|04p,[j''Od3\rAڸվr6:ul:K-I$L:4c,bL1qLKSNXXU4;bًNN(/lSn!LK0̙3L}Q|3zt@ {5qeku~ ݕ=P;;ƵA#ˣt!6nLMn2ώ7ݯySdM&ȡeZH1q2?F.:Yyvƣ`OQwSU+m!us^: WʗUZk<\V[Rއ]2s9]-$nHY{l߳S.\KJ$Aފ%/`|'cw6UVtb`}T<ʩl8 OqU wott:,& i%,/\zd^,D.a̒|9OYdăaм0hҤI0n~ak.fp"-|-P~ 72[,r^4υ.лG/Fs Lޢ/?48I㫯*kVin">ʆr#wީeff<;~+.\b#K;9b59[o7z˒:L3z D.ɓ'⹮oY[5u$?_t{L)ܑD;/@Fr0;#Μ\k ,wLMNT-eZؼAM͔[z{ٝm 7I2%wӇn|!'%3&xC5[zԗ{e^T`2;?,pbறѡJ/DOcM-[B&n!,-BwxdžFnt'-4J'1KtqL4҉ڽؿmdNCE>qR4b9w⃑: y#͚vp?O^v+e%h+7@U ^H^'KѸ-׷0)G뭷Lr( ?亿G_ʈin۶mgCYx_1<dFd7#4E~1.~@.4*3O hroӓ6սLHykP  ?7Lv/qqL{mHZQeoSſ()SNM͔2Ӥ̕njYػfjjnj@#ho2(P&֕{NRxC3\A<pWx{q_"l)0[\jKNC9?-qs-Z;> h}y;- V2{TFKz@7 KM@9IP;%owFbz;ژL-9}Qok[^$hΘާ)9{=Np!/gBZ0E-Bꚲe$'cnd_n<)?[GߐOq+/^d{>~xVx,'iG+8<K;eqGE>uC}>d_,ZlCƍQ̔MYZHfyGВ*pRd%o.fjIjv'[*H*h&+X%]Zgc˨5Kz,5R"sڅ= bߧ٪dO%/`R4,Vky=܈ԓOps:~ԺU?v<ԓ{6i" F}iӱ FyF<ΝvE~1ps_yNwj4p=a'M Mp0t(+ԨQ`0eΜjj. 67"! V,I:,iѼu}k5ā<U3%MZj~ɼN0E_&[6^o%)SKv~qS/xm\ xrb =P^ N\RpwK6orEVX֖)L%mܺixb8=4:JO"FꖼB?VH{1In`)HxeM%o,uh-+}/jb_cK7'驕 prdrE)RlC*[?j~vqd@0-l t:k|,qN#G9ªU2WRE*Uh}YYx?L@l;xw1ntd0w[餇pB-ayբ#Np8Vi/_^+P:$ eAuj@h7(0IWcILG&/fjxCKK8/`s<灵4̟0gyFz;wSnolO4n=˜%f`h'-Z4G~L7`hY*Ϯ]"wS.V0ϱxSO3["焝?3$O )6ns|] ph @L %RK+avi&+p7`IIgKEsg P+i䩁;侲Kdi0SoWdV t$cvG 31fI= 駞 7>΍Ɔv˼!r޼x";KTM;,kYw0a&iz@3D&gϚisD"^ݺ[-|23m/OM)#g0rD$`ôh:Ö mayà't}C x?>Kblq*'V]]s~cwB7w+I_wzzi Xi^`&vr0mِWn9Y40c匶 c{h es8+;we I(ؒ0i#l'[H۳GHĖh􌘘hVupܜIԓOF Ij߾<OU?VC!UV廭0頼ΜбU tIonNAF>I;X0A&Ր`Wm l}^,*Ld:h'1AOY?n`R0X.o=7S, 9*0mzkת/xOdupΔGˤ{|(I9s)!W.n1ゃ~^tuox/`"9_Ly{̩ZaiZ`&((̔',7r<^0UÌIi%s~G~[&wf^>" R :dH(ą@Cf/_t1}{%W^{4ZI;~S`Bst2X&T]wi'0&0GaŜYB2,#`27IG :͞R^c9zdgfKsl\;ξMQO}TѸ)ԕØ1MّfʉoVS ^;w2kܼ;[ʻc l y#GkɆ L蛩$J2D̤ioJ,gzY(0KI>oXh9ؒ0mEa:2ahC-Lv]۶b`&WمF1q9?EΝ:yXɺ GfJrr0< |0p e\i bnл!H.0Ŋ9e/`='oUNXyk'~aٹ9 JFkGۣ|? 7y^(iS 0seZl޼h{.O|6/s=.-ڶMH -h$+-Zw ̐ YĀr&7 qVͲ)4]^Xno!lbL5n(OG- `,. ^={0a6Ɗ{H8`U~&,/p[a9faH!JGA& p3N'hN#* `ҰwdF'\,50wj+X6*l+CLy\4%?vvZ^>,9^L򋼙3ܞfMNtB G:s6wS==|[2q<Rhhp65I%欄.]nv#"aW[~u_, PMt׮]3'mn_L+9[N(/ ])w^"t_(ez/W-&36Ȝm rXwa1fBK76(lӆc^9h$|Th/H04(:Exas 3 GKA@ /~5i]wLFK?o7qi._r#̳40!A?rG6Lٰ开IOڿqLhDZ(+Gt ĒcF>L!0hsMo{%fNAV^U>_9XE[!~r|ǛMz7߈z/oLǑ߷Xd-|=ɝ+DaKh4 8."pH Exbn7Lߢ&#dC^y%tU;9(VYg 0BA.2[BB9 ۺu+ΕC۶mM"Cު+9oox{A -O}q''T ݇i)\9v_|Oͤ1$B75d;׻X\^Wgj}Q7Bqڴowal*U><"i旿%޸Yto͎w ֕%uimW\q2x.DC9^?仩p7T](.ݿ_1Abb̔x9)Z'>̌zi87ĖƎ+uj29t4̵:>f?5i" gs9f0ss{+}*Ix(k0 9-;ie˖RlYsbpk6*5p_6ɇdsiO>m.={V(DsFxx,6ߤ m/slLԬYk?9bzAK^nr?ojJI7L0WyZBKצfzPk]xٰ5[ٲVFg!'-ElyHai&o۵l/6ϲk+eoߤK.aZ YM:\ٱ8D}>`dҦ޺'.+14Vw0שY9b}U':H.s/jx/5L~}/LnQ>? _sQQAK(~raTTϟ`"OaōXs4Yu/D9Q>=9rcL4CL5J''HƺQr!Ef2U-1Ie3ʐ5u1o(<AE/U'Γ0[)Hjd2x3E2}0S!CeF9Q# vʗfu݆II4xx,:*v:Fk ɋr#G0[|m;d2`Z|qA?Qr;s;K޿#d/ "?{?+svKVN8=!t=;e-9Yȗ#?7x+rD9kn?'"G`K37.#teJ?hl.]IcKZ-w/;q"<⌂d~lr0y(UMNHe5ʫQڵ7KF%]d3;J&[(̓\5&kC~mKAFƴ ^hN Mגu&_$7>O5ɑ+gȣݿ;:֑6sFȜM+:]㝥1]n[i!Ujzh {56*O 2j߲JFi>B唥se%Ɣ'NQ&pΑ aNhyq Q(L#4Ҵ]rezTSWˋrftVB5NI*KLteWIZ5Ih9+gK7;Lپ*hLK&|fj0Ȅ 4cM9SfvUƋBj=Y=Gj5ZGokm+ dᖕwrɕ_2h4eNSWMN1BXˉL<ۺ(`L'Rܨɏ(/nϧkt򴚊t+LՎ鬷nqǔ5]\|[Y84Z;ΎUkmOD0"EPBV~Oc} k}yHA lmюi2\RY KoF4|Γ=uK?W*jKx剞?CmZ4/{,|桎);R0v /|S^J jZQY@^䥳j&5ۄE6㺶U孁-͠ր*AhڮL"}LV_>'~"Ucmi0!2kry/<]TQ@(>qj\RKrߍ736_Aig|kgzr[ YO%upyqR%hŎ O.Th 'z5 D!ߨ{K~pp0ifڑxBhEtt@djrOi:)kj oj & (7+`ѿX=a08fsipˊ\*,j4;jWhh@!~;TK&W[iMJWvҺ-ҎV|YNȮ7T7R}o@ P)fyEQtPxfz4\ Em<9].IdEktzLӍ6Z5~uQ'L4;Uֿ{h44$4z@dZO6s6./Ԕea-qj/YqfZ.S5G>Su' 7V5S5l@tл< 3=zf˥I1q_AVv@[fh:,߾N^Զ~фkC'gܩuZ>ÔGZ *ց`ZVv}{cŘ*`FB `\ҠV-p!4FLw%Y區YM5>S5F+81:rUb "iP+[5/_/S^M2 .XLÓ;+O eh?b;K7sh ~jh 6Stug2I?y~H? 7]?6UO*F`7#MfTnX}Lem۳CM,AmժX5jmq Z{/dG3upb`[ӈN@j_ycvYV9 _mLRL%ܫZi #5 T e, g0ظ{MepĀzߪZ ֜0s JT@Gf13 SjIz 3 PO\g:myw8<: 9jk΃yM5H:  FI -ژNRWJ#+f?fy'{~dj`u^"@jRt\N@ α]QQIK팁2|V.\+Hz{[Okky C5&ν`6ш3,0+ hЯS9bڅ)=#@*0W*]]RxagDkNT9_)`QjϚը(ǵo3\FAKfs}éI0+mjڥ:K]o@UOΏ*]G$@mmޒ7OGgj^2}f M4b thCFr:k Lj]t(LB4-S9&濠1*ÙǎI爝9X;&5ךE'՚Ԏh4G+M1*O^-jb}_ck|@ Bjc60}Nm43ɑVUÀfeS*m`@yzλd:F-fqOs3L߮@|c0m$W`A#vkYiQ  D븖LQwd5/thwT.'&]b텅jRs24D- hȘqQK,,!~- /WQovHOL2ݞ*ڪ;] Z>M++, Z< Sڹ'3q}ɖmfQbw,"tzʥ]˃lx('ibсA1Y 4#ʔ#@9_ƭo4k҆)yLTfk Dy.ҴUmm9=^Rdaʬ҇?wl8ꃭ9 gISZ? :sleZ "rBi7!y䍁rjd[wUm+_'GVkkbڤO#oX-8EqQ~n~ /LanQ{^Y aUW員 Fd`1ɜ)S8啝s/JH*Q)(s+̽T<Q1hru3zff {?-9"nrTR(G\eܐ IENDB`nUz?.çD*YPNG  IHDR}:H;D pHYs.#.#x?v iTXtXML:com.adobe.xmp 0_JIDATx흽Jm;wNEJRpFII4H$ L8 ,H0$G>v|.Z?~'  >4^'Oo?@ ?᫿;ۿSfH#|i7)|/郴>}H$.|# 4s'G9 }WhOғA@>=>!}H4ʇ }p(||%m A|+<J }uom>HCжHƃm/o |#m A|+=EH@ k uoj'SjgE }_z·жH\7m> >,sm>njH }pΆ@% 5S;Wz /$}7{@3 uS;{vִ ?'S1)v>iH_' }tjH"}Mli_>@^to ?J^R>@H䚝;Y{fƢ{PQ~#}g//ǟo'7C黁Խr9C;OAnSW+}ۄSDw\& !j"OM$KB?v$H_rnp&?G"%[ZtowkMz|0RQ6D7϶PAhKD*%&CrϛG; ^W'w-j#1T[m._!uI݌s}HWi{ג-L$IE~Bd&"R>W •\B}\Sآf!oKl1"[UC|]8א] hCO*B;Q!wMUFLD {+kΪTD"ditbH9".gi)Eou"VšO"}yNduHL_"d1SBJ%g3tDrRQ>@¦s"J=IT::#yޛtUL]S+@<_!^"dRT??yX}c%ߐ砢, }WyK#3鋕'-9RGUL}|dd#v"}y ? DXϧ QEMNE\E$CV} ډA T>н1!y_8!:< -Eld[R("l׳} IOPSǝ=r<7 a/TRTDTX".!"[gF?[;}?lm]~Ó'(}u"rz Pr}}}BwԺ(sr*]gj ˷E|϶<Ae,}ƦL6tآ< ԊV]QiOʧ_,/)RT,xPJHpvTd*Hq>@ yMO]c'xk鐅Cۗo/Ք]yQJ~$rɔI#}D6 } 8(I|ӜCKO{,%pʧIU'vy&EK"|rQ:W:Ff%*w*1o$zM$2hHtDHY5MO.E\E$%#ľS]>@ҫLp9'E{TXsM퓒#Ng̽d kkފ*SZ_yU*\FWMPwp>ɈϽtn\"[VU,RA i&ҾXѿ>]O2"31mNLdJҏwok.~zX{*e6F/G'ڢQC}]d:"pm>@%x F?s>mh;.ϤC#u #]>@2/1oSIE}pR6RiGo|J&~[D郻ދ&&Vs6)~Rsg.Z\ۇҗHn|)==Ӑ>Isl(IIgw1t*m}GOPgtr| |Ca颡VSRdtQH;a#,tg{GL ULϧq?#UH,m&1%%GB!r>M~"}]Xt%bۧV?Q2 >?ڣ8 ;".G!]%|<1P/ HުoL"F}U' 2irPľijLMKA~ɟIZ0HѽO@OJKO9?RTY>&Jl!wޢ敎Vz_K4>=jߎWJ Rm}UYuSJm3>@5(Os>oktmˑ PE01~H_~i^;OE\>=j#pg{ʤΉ; &u EnHYⷥ:Cؗ{pẫ*@7[3>=Xg8to飒iPi-JKi( ~H }BZP2߸?S铈Ɯ ;W&9꠹}D8d49CK41=Ux,}R5ϢpRi%C|LI)%!L:\wH rn36ekTOy>Ys-EYR%*YETMo; gNzTG?D[U>K[Pq RG*|K 9RLJEcgx;H_b)yOU8JJKʃUO⣻7Jꌻ-Bw/h(FHF$u^23t7"}Lm釒qA '~W>L|IDٖ*r&bO*dL".G΀DK`A W|H#)LD$uٮNMKK_Ƀ]QB?%OȌ81&e>%)dJg"}!|KEMo! (}!|B"jH3,*]S D/*sF$]M֙Icq6Q*d.Tp/E-X!'[n~cJ3 ")HDKOϨH>y5铚4-T-[J76qFKc=z9"&j!Q jҷG%Q|eDIoKW}OKMψ=>@)2,="pIDngog"&yX".9E$SjRtolJ?`+ITjRdBdD66之 :H }i_w!ѰMi%X&}^8M)>ELZNKD2TVOxb1 |IݏJ핼IUxtZIF|L<;RMa}3jRG2ԙ]IBXs/QhH]t? 3'+SGR\Y$}!d)Fts/Q256]1sLc>Ek>!|_nP8UOJy<|@~=_EIEz>SB$<+阌e&iG{2+WC^E&ϒ{|TStIIotǭ M#wl޻'p_>y:CbQIMSޣ9;M2eLgknokOXT)Exe^H]@nɈd,2";#}p[)g᛹/".H:"{g۞M+ur8@ 铒% ~&9q *ǡ#}pyo,:p'%>V$<,:N<*LPiHVOJ|sv>aCG$C_:H\ZaOj3j2tE\)t>mFNO*]g*X'Y%TD2ƞKT^ӳ>Rx ["HZytul)qvo ѽF{¾c/})q }YtGE\BD$Cّjwו>Le I>>F:]笘K}+EU2z=.+}Q Ge.LsttAS9BnIdJTviH\_| IT".ΝIQKol [ڊH}}"zl_ }\' n2DoBo!}p}ML`M܎H@>IF \m[>@ GHLV!븉ѤVe򖾟BpVIHO\P1 +{)} Q>J$$}DRV MHOZ!髸iI" |37 1<'}=\+} \.(}U;,OjʍHSfR;.(}[v\Wv\WdIs>j=p]o)}\WVAI`qewBC;N@VnqJ }< +u|~%p+24-:]fHҧPJT9Vi(nC\6g޽xJa/$֟BӸˇa J ~ ,@CnrIr WPT4ocCyg{5!˜ܾMl` sS:'YߨQ$y$D㋄W$ ĖC]ճd"}jz @'UbpL-diLĬY#}]nܧW"KPC25>u-ZK/B<բEϑd=킨~$$=-zk^SO~O͛޷RPר="}!ĤƑ) FEa9kCg:hX OYTG%zQo⸆Rla͐A>/,Ru# ߯@Ҙ?L5ws[{Bp[He",U!|_$[Q|=?oql4o W7 )}T+$e"|/( yU+,-^hH_Ew1Ȳ0 }o慭&>ʝ n^E߷ڪdP2+Z^A-//b `7|nH_$1ֶcw}?3dTZ&җ T Ǿ>H_4ӭ޵!}YtFOTH%w}a's W_ +y$.d#ѾŇV=uscA˽2>tw\%gXV_BҲ(69u*7 SqC+ lu7o;/(z>p^%n0Sv΃f= ('Z;P3ҏ:? (,VzO#q-gmpGg0I4Q)浜 PfAHjFg:g]˂ IsdV4܇i0\6&Yh <}_mpڤM}){2/I_s!`noioɧ3P . |!-}հH·&}㝤~~_e2_E5 {^ 6ryI#6є%>;L/J~%1ё>S/x@،"j/ʙ RJs>GP扞wAs|0x.!1= H\S }nꖞyP G[b?|LGIJך_Z l >Qjowݤo؄xt!e6W`(-[D&Ub׾ؾ VY${G%OwBuQF|> eWn0|nkO3g3kW qŲ0Neov EeRpyywM M˔O &wBl"stV!UWg\AQAp:W4(DVU)tϕ}!u f3[Sc() $YV;)}RFO5t}YjB`Nݝ9}HL |9MaHPn.?'o!}/QogJR'gAvABs?U}%D&4/_$ <ߣйK#8E "Т)X!pH!MowoZj9mOH_a&ҵֱa,7?I=CH>VcSF?#lG 鐾ty221F4IڤDՐ"ѭ3W55Q,>˕ ys9w7wg\8f?g"ŅnDo1gqN#-t;1KNq~=%E :'\fL!hzK$^zb=YFaQ=-t ')oɝaf9#H_OCM缧o~,R& /$5AiT{JQB#BE,j~@:|jQAjg0% *uw5}m{~9ȍXK+"2zB.CX8 zf/q3c29e.KpI#?>3=bd*}cHAi/0^5H_黗YfHߔH_7]`u/nk}=aRzql8PwڛHnn#3MHB Ji]:/dg|\ˮz'gkO6yrXM57>~xE"҈y3*X<>S ;}ֹe A)| }Y4/RQڄM)k%ϰ_בVu3}K^Ԥӑ f,}C*#2'AE ʝeY,#ш9!#l>HD[eFWZpvO/C2\!ϖ?u##w2t$,}E*jg0k`k2]wMy5%fIp"~}.-XY|wH璪e.%+˾Rd 7>˾_QߝC>1ӫS?Ő;I泬-%8W5VEWf/Y3x+J_#)hjaxMMu .s 9 <*1DM/;qxz>9Lߩho:i_#1Dh:;HC兤O7"6Sχ{w4. eE6G{z>yC(טʻ<:HaR|ìsNﴜ-xC.'PwV}rF\JҢYP2^fz-,MCv.~?;3YE#}z nO]]$hR>e|6#ub0Z\nJ<: ӠM&3JfyAw">v죜#]IE ]ͤ(`ER՞2KĖ>>vOlr5mqpVm1G?Gs ݥa[>3ْXucx]ڼ }E_?/m-\c].ni?f)x 6R*|7\lc蹓>oL'Bd/佗ܿ53(M.>>Pryw .>=}J_ws}'$`0&FуOGvq 铑Hʕoqx]Ue3@gbqqܦ/2[Fy"1$8*}V u~g(V[`> %DJ_,?Y{^3o9}ygrzw{h&Hx |BF)Puw{To1Y j*ا+p>6ҿ2H]Ǿ.ZBϛI.z_N|2ܚތ%(zt*QiIZ ,@r2?Jzw[eҗ9_G!2Eo@uJ@̄/?O{1#}HJ_s_~fg*f/C'gsO>/MyRl&iN !}HJ"E*N:BJ=HUB.d>leodD>/}NuOԤOe mE7[\g !}MsIn҇!}A.5IXzk#%*!}59!}H)[>IXt=_s[郴xʮaCI}h5Śt~]}LB>*B)7 CI5~3rt4T9|OF>HX&⹲ !}$SX,]U C ]o (}8&1Hݛ2xYB tK@|Ohޓm٨f2NoSëMeP[cY}Bemum1qö?$ Ŗykk볭Թ)W>iݏOe-V?5wǧwԵQu {y5ʰ>wtq7ǂ EA˄V$;=ȋzJNdzILJtpb#ؖ`MF띭$ }YM Ua~ƈh2OJUG6i=HvR}.v1@y>#2&' OAO|R&yRw'"cYL"2Dr>uL<oӹ^YQ*}d:^*}g O }~6]4>Ǿf>"AY.FM&6/B( WMBmL o ҧ'}jxn)В> (K"[Ӕ eӽ]PgvWWjZ\|k0@^ܕ`tyU΃8tq+|M=g;>Op!)}&g{_KQ>g 5^,}.AJFٯOpj7$` H<$oA,5QiJS ܌V|%#}>JD A@sޑa B+ǔf@i/>N:i*|}+urtnpt$#TG;#9ioJLH㸄Mߧ;xzWCF]![W$I7@җ̤äRg4ĵg[ [ޏcU\V)/ʑ &/αUܖL/ <|껓dxbK_\R }t*gX U}~X.J}uXI΢MYW Ss)2 Hi # |V #x&ִOYNR>dNk_UtӃ')&"#kyyi~0=E^[0>O$hg"}M tuԳI"%|IOCG92>DBbҧV _ҷNi~<ς le_G9 +}> Ji0W{8?"}Bw}E &'Z')JAF9 dt3cJ,j6xM}_KO, } G[al"IQdEW1LW!'H,tB25c #)}x;wd+}Mh oOCUQ1cmRuPʛJ_\ݥ>-Ƽ\ap~-|hiѭxK9 b;:_hҧ#}牢ֹw%E}qMYmvE ]wfOt)sI5 Dܶ\LR5}@Jkk}YE7_[4|KKe` }f[D`u9} owdFBE>ŕPU01'4/)k<,`q!)(FxyF/`y)ڦ _:Tj=NT]cE>);_VA9W#}ۯ>s8&^1t/͓Rf࡟\AtĒ>ãJ>gx>!җ)NI#XK  k>ț>}VCft }n+!o7ٔZ>5!}QD"}Wu.n>Prh:I3\t/>j!K`O῵Վ޲ʛHd0:{۽1 }b"}bGSDYPGNoAS_U*dž?͙'ٳc4EV=}Gà&fË59E4'/}էWuKl }xU'0~/.#}"{ĥo>Ͳb}Å'/qbE4BU5Ǫ%s5߃P!}fGԱƛo0X(줯Km U1, F$B qiM/+3{+vB":NґIʀSҧ.B%秌|i3'qj!5> }G./}O)Dul4VLĤo0{Ĕ/I_Sd:3kR|W"}}f}5Rg`"@"}_AwG obutФ Ga&1oR>ʓՍM1& e Hֱ;{SPϗ\r(7i,&L0hRL,i#?>ql6xQf`Z -5m1 L>jö[ьkA}>.&}U P#}7H,bJ_9瘓z827/b:1_T!=F'DgIsWTTp|jBJA|^iPcHn&}خY^Id+ԿөdLAΥ2 KFTȾ]Tʌ&u"m=VLf"HYiL"%P[X]Ck?Td°ݣZZG>җ`x9XF2Q? rW{,+Q uIɡM :j8ɾi@,}’*Sx җ d3,pKT@ MFD&sV [Ǥq|4Z `0tVZGq+{]V5tԼgE?>8ч'>_ꜯԍt/Ԟa=*҄Rrͅb,i>ZZ)<{@~Sf .Nj]I2m`eVvy)]6|?sоs5RUxh?M?{%o޻M7{7 TG/8~7n$}GsUƩVoH?⓼*{ rȺľ @*M&| @*aaZnV~IZ;Ƀ}f)fR7>HYN S~IY\=IEyÉ`"fcbQIIhKe'z9.oW }ps,~-W;s^.i'v]3@?M$ sH }و߂HߵŏHv4H }L,e*zJҗ1)xT𦡝KWє@N@遡!} _WU!{H }a'*D@o=,e}$~~ {F җdX]'b #}eϏkREWyd1j3>#u>G%|lD eS[CDժ }M Q#JEQDd/".b729Cb#}=Y _>8KQ-}sNc )EToUj2<06 }LmL~H(є4]Z*t{k&eMJ&cso |}{ݠ} ΓaDv=Soj k6ѯ .7Qr8z̥zř>_ >W{(23 D.sf&y= .}|Jc$[lĩ҈P`!}.&5鳔ߵe?Jߨ3V>nH҇niE+y*v ܢddc/#;.>_'p,+5HTDD\@2]YOZ K_{\K -۽FoL\>|՞\R8}JJq g Xtn/-"V6Ƅ}@V7 q,%yVm6{ޥfjg-ǀ4.w&%=|:}mHTHعG@_lfI.}^n#}?Dw$r0,  "Vl2YMH}1 6 KGֳگV_c;yh_d"}/}IX6Ghz'҇GchJ_)HeJVщtՙ r7tަEұT HߠAIvd }Yy|BoFK{b{Et}Jm>qmehܓ2AkO*IJWy(Yu D(3/6d }s%[]Rf>/7/x5nSŃFr[biA[4 J_i!d,G}ڷ< }[*Tx>>/wT V gE>huL;5Y1Il=KߤkɊQ.1-(b5i9#)J_U)Hɢ'| }H?!HTNQ;rd+5>W$'<."SM41H_)n{C*}A_ Ow>> Y|L黌>ݫW$W^EL&雥QV>v8)sJ_wS>EW!RQE^z7I_ypܥO#QdRHLcHB|NC ;>lX4['}'|m[w6ؒKO"}E.A'lAƔަXI I%qB{s>{,H"K@Jw U7Ӗ ڗup;GFkm&JJVâ$bJQi<Ypp>9H^޼KHn/E( ~Ikr=)&~$s=Z"K"l,Us}4el'}a6f:(ZC볃-+w=ySV.&}+J,Ypߥ4L}OCL,$H~I43A>aX8;>XvDi4VE(YقRnSwFg& ݾuK74M+=j Ck?L?Ҡ/$$If!vh#v #v #v :V l05&5 5 5 / / / / / ayt->$$If!vh#v #v #v :V l05&5 5 5 / / / / / ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l405&55&/ af4yt->$$If!vh#v5&:V l405&55&/ af4yt->tDeCheck1hDe$$If!vh#v5&:V l405&55&/ af4yt->$$If!vh#v5&:V l05&55&/ ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l  &05&55&/ ap &yt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l05&55&/ ayt->$$If!vh#v5&:V l05&55&/ / ayt->$$If!vh#v5&:V l  &05&55&ap &yt->x$$If!vh#v5&:V l'05&55&ayt->$$If!vh#v5&:V l  &05&55&ap &yti x$$If!vh#v5&:V l'05&55&ayt->$$If!vh#v5&:V lx  &05&55&ap &yti x$$If!vh#v5&:V l'05&55&ayt->$$If!vh#v5&:V l  &05&55&ap &yt->x$$If!vh#v5&:V l05&55&ayt->$$If!vh#v5&:V l  05&55&ap yt->x$$If!vh#v5&:V l05&55&ayt->"x666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666$OJPJQJ^J_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontVi@V 0 Table Normal :V 44 la (k (No List ~~ Table Grid7:V0PJ_HmH sH tH D@D Header$ B#da$2/2  Header Char^JD "D Footer$ B#da$2/12  Footer Char^J:U`A:  Hyperlink>*B*^JphB' QB Xy0Comment ReferenceCJaJ<b< Xy0 Comment TextCJaJ>/q> Xy0Comment Text ChartH @jab@ Xy0Comment Subject5\J/J Xy0Comment Subject Char 5\tH RR Xy0 Balloon Text dCJOJQJ^JaJR/R Xy0Balloon Text CharCJOJQJ^JaJtH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y  'z  f ~ 0r #%*.169;% D K N m t w { ^Edqw ,p  !"$&'()+,-/0234578:<f#!1K[ XXXXGG  /Xb$F}? =Ά G7z,b$z?.çD*YV6,@ (  V  3 @A #" `?  S A  http://goshweb/corporate/communications/Documents/Brand%20Hub/GOSH%20FT_Logo_Colour_RGB.png#" `?(  J  # "?J  # "?J  # "?J  # "?P  3 Z"?P  3 Z"?P  3 Z"?B S  ?#En tH ttH ttH ttD;S#t@C t@_GoBack  il    @GejGNEK    333333   PjQ(̘.lfvy^`OJPJQJ^Jo(^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hH^`OJPJQJ^Jo(^`OJQJ^Jo(hHop^p`OJQJo(hH@ ^@ `OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHoP^P`OJQJo(hH^`^J)^`^J.pL^p`L^J.@ ^@ `^J.^`^J.L^`L^J.^`^J.^`^J.PL^P`L^J.lfjQ(         jZ        +hz'&g i oJ$(y-y/X[1k::<"DGDKXGJJ]XwXy0I}{ E9A a"+RxeJ )PS%5<o ,->x{ @R 8@Unknown G.[x Times New Roman5Symbol3. .[x Arial9.. Segoe UIA.Arial Narrow7.*{$ CalibriC.,*{$ Calibri Light?5 *Cx Courier New;WingdingsA$BCambria Math"h#䂧#䂧U U !24 KQHX  $PH2! xxi "Paediatric neurology referral formZReferral proforma for paediatric neurology. To be used for urgent admission / advice only.nurology,refferal Claire Davies Ceri Wild   Oh+'0(@\hx    $Paediatric neurology referral form\Referral proforma for paediatric neurology. To be used for urgent admission / advice only.Claire Daviesnurology,refferalNormal Ceri Wild2Microsoft Office Word@G@U@UU  ՜.+,D՜.+,L   +  #Paediatric neurology referral form Title8 8@ _PID_HLINKSAsH %mailto:gos-tr.neuroreferrals@nhs.net k&mailto:gos-tr.neuro-referrals@nhs.netsH%mailto:gos-tr.neuroreferrals@nhs.net k&mailto:gos-tr.neuro-referrals@nhs.netr\http://goshweb/corporate/communications/Documents/Brand%20Hub/GOSH%20FT_Logo_Colour_RGB.png  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F[Z$UData 1Table2WordDocument9SummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q