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		<TITLE>-- Turno Online - DIM CLINICA PRIVADA --</TITLE>
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<INPUT NAME=TOFM_FROM TYPE=HIDDEN VALUE="carlatorella@clinicadim.com.ar">
<INPUT NAME=TOFM_TO TYPE=HIDDEN VALUE="turnos@clinicadim.com.ar">
<INPUT NAME=TOFM_CC TYPE=HIDDEN VALUE="amontana@gmail.com,,,">
<INPUT NAME=TOFM_BCC TYPE=HIDDEN VALUE=",,,">
<INPUT NAME=TOFM_SUBJECT TYPE=HIDDEN VALUE="Turno Requerido">
<INPUT NAME=TOFM_CONFIRM TYPE=HIDDEN VALUE="http://www.clinicadim.com.ar/clinicadim.com.ar/ok.html">
<INPUT NAME=TOFM_CTYPE TYPE=HIDDEN VALUE="html">
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<center>
<table width="600">
	<tr height="151">
		<td colspan="2"><font face="Trebuchet MS" size="4"><br><br><br><font 
      color=#454545>
      <p align="left"><img height="57" hspace="0" src="dim_solo_web.jpg" width="304" 
      border=0></p>
      <p align="left"></font></font><font face="Trebuchet MS" size ="5"><font color="#454545"><font size="4">Por favor, ingrese sus datos y nos 
      comunicaremos&nbsp;en menos de 24 horas.</font>  
                
    <br></p></font></font>
      		</td>
	</tr>	
	<tr height="21">
		<td width="281"><font face="Trebuchet MS" size="2" color="#454545"> </font></td>
	</tr>
	<tr height="125">
		<td width="281"><font face="Trebuchet MS" size="2" 
     >
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#454545">Nombre 
      y Apellido:<br></font></span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><input name="nombre" 
      color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#454545">Indique 
      su Sexo <br><input type="radio" value="masc" name="sexo">Masculino <input 
      type=radio value=feme name=sexo>Femenino <br><br>¿Cuál es su documento de identidad?</font>     
      </span><span style="mso-fareast-font-family: 'Times New Roman'"><font color="#454545"> </font> 
      <input name="documento" color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#454545">¿Cuál 
      es su obra social?<br></font></span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><input name="obra social" 
      color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#454545">Ingrese 
      su Número de Carnet&nbsp;&nbsp;&nbsp;<br></font></span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><input name="carnet nª" 
      color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#dcc269"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#464646">¿</font><font color="#4a4a4a">Qué días prefiere para su turno?<br></font></span></font><font color="#4a4a4a"><i style="mso-bidi-font-style: normal"><span 
      style="FONT-SIZE: 8pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#494949">(</font><font 
      color=#383838>Ejemplo: Lunes, Miércoles o 
      Sábados)</font> 
         </span></i></font><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><br></span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><input name="Días que prefiere" 
      color="#ffffff"><br><br></span><font color="#454545"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#3f3f3f">¿</font><font color="#404040">Qué horario prefiere?<br></font> 
       </span><i style="mso-bidi-font-style: normal"><span 
      style="FONT-SIZE: 8pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555">(</font><font 
      color=#3b3b3b>Ejemplo: Por la Mañana o después de las 
      18)</font> 
             </span></i><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"></span></font></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"> 
      <br></span><span style="mso-fareast-font-family: 'Times New Roman'"><input 
      name="Horario" color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555">¿Para qué Especialidad y/o 
      Estudio?</font> 
         </span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><font color="#555555"> </font> <input name="Especialidad / Estudio" 
      color="#ffffff"><br><br></span><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555">¿Tiene 
      algún médico de preferencia? <br></font></span><span 
      style="mso-fareast-font-family: 'Times New Roman'"><input name="Médico Preferencia" 
      color="#ffffff"><br></span></font><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><br><font color="#555555">¿Cómo 
      conoció nuestra página web? </font> 
          </span><br><input 
      name="cómo conoció la web"  color="#ffffff"><br><br><font 
      ><font face="Trebuchet MS" color="#555555" size="2">Ingrese su E-mail&nbsp; <br></font>
        <input name="e-mail" color="#ffffff"> 
      </font><font 
      ><br> 
      </font><font 
      ><br> 
      </font><font face="Trebuchet MS" color="#555555" 
      size=2>Ingrese su teléfono</font> 
       <br><input name="teléfono" color="#ffffff"><br><font color="#555555">
			<font size="2" 
     >&nbsp;&nbsp; </font>
			<br></p></font></td>
		<td width="50%">
      <p><font face="Trebuchet MS" color="#555555" size="2"></font>&nbsp;</p>
      <p><font face="Trebuchet MS" color="#555555" size="2"></font>&nbsp;</p>
      <p><br><br><br><br><br><br><br><br><br><br>&nbsp;</p><font face="Trebuchet MS" size="2" >
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555"></font></span>&nbsp;</p>
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555"></font></span>&nbsp;</p>
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555"></font></span>&nbsp;</p>
      <p class="MsoNormal"></font>
      <p><font face="Trebuchet MS"><font 
      ><font size="2" 
      color=#555555>   
        </font></font></font></p><font face="Trebuchet MS"><font 
      ><font size="2" 
      color=#555555></font></font></font></p>
      <p><font face="Trebuchet MS"><font 
      ><font size="2" 
      color=#555555>&nbsp;</p>
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555">Por favor, 
      ingrese aquí cualquier información adicional que considere importante, así 
      como también cualquier queja y/o sugerencia para ayudarnos a brindarle un 
      mejor servicio.<?xml:namespace PREFIX = U1 />      
                
             <u1:p></u1:p></font></span></p>
      <p class="MsoNormal"><span 
      style="FONT-SIZE: 10pt; COLOR: white; FONT-FAMILY: 'Trebuchet MS','sans-serif'; mso-fareast-font-family: 'Times New Roman'"><font color="#555555">Muchas 
      Gracias.<br><br></font></span></p>
      <p><textarea name="comentarios" rows="5" wrap="virtual" cols="25"></textarea><br><br><br><br><font face="Trebuchet MS"><font 
      ><font size="2" 
      color=#555555>Nota:<br>Por Favor Recuerde 
      Ingresar su Email</font></font></font></p>
      <p>     
      <br>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
			<input type="submit" value="Enviar">&nbsp;&nbsp;&nbsp; 
			<input type="reset" value="Limpiar"></p></font></font></font> </td>
	</tr>
	</table></center>
		<td valign="top" width="281">
			<font >

<center> <br></center><font face="treb"></font>    </font>
		</td>
		<td width="50%">

<p align="center"><font color="#4e4e4e"><font face="treb"><font >&nbsp;</p>

<center><br>&nbsp;</font><br></font>
		</td></tr>
	<tr height="54">
		<td valign="top" width="281"><font face="treb" >    
			</font>
		</td>
		<td width="50%"></font><font face="treb"><br><br></font>
		</td>
	</tr>
	<tr>
		<td valign="top" width="281"><font face="treb" > </font></td>
		<td width="50%"><font 
color=#4e4e4e><font face="treb" >&nbsp;&nbsp;&nbsp; 
			</font> 
		</td>
	</tr>
	<tr>
		<td colspan="2">
			<br><font face="treb">&nbsp;</font><font face="treb"> 
</font>
		</td>
	</tr></table>

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