{"id":39,"date":"2021-06-25T22:16:34","date_gmt":"2021-06-26T03:16:34","guid":{"rendered":"https:\/\/econdental.com\/?page_id=39"},"modified":"2022-09-23T17:19:10","modified_gmt":"2022-09-23T22:19:10","slug":"new-patients","status":"publish","type":"page","link":"https:\/\/econdental.org\/es\/tratamientos-dentales\/pacientes-nuevos\/","title":{"rendered":"Pacientes nuevos"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"39\" class=\"elementor elementor-39\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e861c63 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e861c63\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-edf3308\" data-id=\"edf3308\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-abb6a75 animated-slow elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"abb6a75\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Formularios de pacientes<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ff50a6c elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ff50a6c\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-a095850\" data-id=\"a095850\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f9f3b24 elementor-widget elementor-widget-text-editor\" data-id=\"f9f3b24\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Le agradecemos de antemano por la confianza puesta en nosotros.  A continuaci\u00f3n, encontrar\u00e1 una forma descargable con el formulario de pacientes nuevos.  Impr\u00edmala, compl\u00e9tela y tr\u00e1igala a su primera cita.  Eso nos permitir\u00e1 m\u00e1s tiempo para dedicarlo a sus necesidades dentales.<\/p><p>Llame a la oficina si tiene alguna pregunta. Estamos para servirle.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2de528b elementor-widget elementor-widget-toggle\" data-id=\"2de528b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"toggle.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-4811\" class=\"elementor-tab-title\" data-tab=\"1\" role=\"button\" aria-controls=\"elementor-tab-content-4811\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-right\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-chevron-down\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-chevron-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Ver formularios en PDF<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-4811\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"1\" role=\"region\" aria-labelledby=\"elementor-tab-title-4811\"><p><a href=\"https:\/\/econdental.org\/wp-content\/uploads\/2021\/09\/Bienvenido.pdf\" target=\"_blank\" rel=\"noopener\">Bienvenido <i class=\"fas fa-download\"><\/i><\/a><br \/><a href=\"https:\/\/econdental.org\/wp-content\/uploads\/2021\/09\/HIPPA.pdf\" target=\"_blank\" rel=\"noopener\">HIPPA <i class=\"fas fa-download\"><\/i><\/a><br \/><a href=\"https:\/\/econdental.org\/wp-content\/uploads\/2021\/09\/PoliticasOficina.pdf\" target=\"_blank\" rel=\"noopener\">Pol\u00edticas de la oficina <i class=\"fas fa-download\"><\/i><\/a><\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-fef2f09 elementor-widget elementor-widget-text-editor\" data-id=\"fef2f09\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>O si lo prefiere, puede rellenar los formularios en l\u00ednea.<br \/>Sus datos llegar\u00e1n en un correo electr\u00f3nico de nuestra oficina.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f3a676e elementor-widget elementor-widget-html\" data-id=\"f3a676e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\nwindow.addEventListener('DOMContentLoaded',function () {\n     document.getElementById(\"form-field-patient\").disabled = true;\n});\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-aa6c365 elementor-button-align-end elementor-widget elementor-widget-form\" data-id=\"aa6c365\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Back&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"dce-conditions-js-error-notice elementor-message elementor-message-danger\" style=\"display: none;\" data-no-translation=\"\" data-trp-gettext=\"\">A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.<\/div>\t\t\t<script>\n\t\t\tsetTimeout(function() {\n\t\t\t\tlet el = document.querySelector(\".dce-conditions-js-error-notice\");\n\t\t\t\tif (el)\n\t\t\t\t\tel.style.display = \"block\";\n\t\t\t}, 6000);\n\t\t\t<\/script>\t\t<form class=\"elementor-form\" method=\"post\" id=\"new_patient\" name=\"New Patient Insurance\" aria-label=\"New Patient Insurance\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"39\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"aa6c365\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"New patients - Econ Dental\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"39\"\/>\n\t\t\t\n\t\t\t<div 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data-field-ids=\"[&quot;field_57ed1c9&quot;,&quot;name&quot;,&quot;field_c72d2ae&quot;,&quot;patient&quot;,&quot;ss&quot;,&quot;fecha&quot;,&quot;field_3242de1&quot;,&quot;field_ba63340&quot;,&quot;field_92facb7&quot;,&quot;adress_employer&quot;,&quot;city&quot;,&quot;state&quot;,&quot;zip&quot;,&quot;field_56e3526&quot;,&quot;field_2e04a9f&quot;,&quot;field_0f02a94&quot;,&quot;field_bf6b69b&quot;,&quot;field_4b28dff&quot;,&quot;field_2deb87b&quot;,&quot;field_075f5cc&quot;,&quot;field_9b0f536&quot;,&quot;field_fafeeac&quot;,&quot;field_668fb80&quot;,&quot;field_3ee3c94&quot;,&quot;field_299286e&quot;,&quot;field_e5ac040&quot;,&quot;field_86c6449&quot;,&quot;field_09b16dc&quot;,&quot;field_8d5faed&quot;,&quot;field_63ca89c&quot;,&quot;field_fef81e2&quot;,&quot;field_a4a14e7&quot;,&quot;field_72ead85&quot;,&quot;field_85a2a0b&quot;,&quot;field_7b7f24d&quot;,&quot;field_b68c0a9&quot;,&quot;field_7f9da96&quot;,&quot;field_b9217ae&quot;,&quot;field_bf2f7ef&quot;,&quot;field_c767d58&quot;,&quot;field_41f2687&quot;,&quot;field_e3bde48&quot;,&quot;field_e7a5b4c&quot;,&quot;field_3cbee20&quot;,&quot;field_44841fb&quot;,&quot;field_7c8990f&quot;,&quot;field_c050482&quot;,&quot;field_1c24ef0&quot;,&quot;field_772df95&quot;,&quot;field_af1f278&quot;,&quot;field_ea3ee39&quot;,&quot;field_956232b&quot;,&quot;relationship&quot;,&quot;field_2bca0c9&quot;,&quot;field_e07af4c&quot;,&quot;fecha2&quot;,&quot;field_0abdb1c&quot;,&quot;union&quot;,&quot;work_phone&quot;,&quot;field_cf5e3bc&quot;,&quot;field_5c6b9c0&quot;,&quot;field_03a544c&quot;,&quot;field_eee4356&quot;,&quot;insurance_company&quot;,&quot;group&quot;,&quot;policy&quot;,&quot;field_078ab4b&quot;,&quot;field_7b9e78f&quot;,&quot;field_4973c26&quot;,&quot;field_49c7d6f&quot;,&quot;field_809790d&quot;,&quot;field_2dfb088&quot;,&quot;field_e3b2409&quot;,&quot;field_0b294af&quot;,&quot;extra&quot;,&quot;field_a0e9d66&quot;,&quot;field_74dbece&quot;,&quot;field_e22d640&quot;,&quot;field_e429e76&quot;,&quot;field_04fa567&quot;,&quot;field_515fa9b&quot;,&quot;field_6bb19a8&quot;,&quot;field_e0d330e&quot;,&quot;field_cacfa12&quot;,&quot;field_5b2400f&quot;,&quot;field_064d903&quot;,&quot;field_250d35c&quot;,&quot;field_3b98d99&quot;,&quot;field_ff376f4&quot;,&quot;field_091c3fc&quot;,&quot;field_56c0d7c&quot;,&quot;field_bcecc10&quot;,&quot;field_0af3444&quot;,&quot;field_338364e&quot;,&quot;field_1dd003b&quot;,&quot;field_58d8a3c&quot;,&quot;field_9be1222&quot;,&quot;field_7447e4a&quot;,&quot;field_3a6ff2c&quot;,&quot;field_38fed77&quot;,&quot;field_bfd9c44&quot;,&quot;field_7ac29df&quot;,&quot;field_4ea1b61&quot;,&quot;field_ca6d67f&quot;,&quot;hospitalized&quot;,&quot;field_c07df65&quot;,&quot;field_d3f23bf&quot;,&quot;medication&quot;,&quot;field_06834de&quot;,&quot;field_1f76dc7&quot;,&quot;field_730f92d&quot;,&quot;field_7d72066&quot;,&quot;field_300c1dd&quot;,&quot;field_2c30b47&quot;,&quot;field_ac55f62&quot;,&quot;field_a44509e&quot;,&quot;field_8910343&quot;,&quot;field_65f4c95&quot;,&quot;field_888ba96&quot;,&quot;field_dc86106&quot;,&quot;field_a0ec057&quot;,&quot;field_6e2572a&quot;,&quot;field_6392435&quot;,&quot;field_d50f8fb&quot;,&quot;field_36ac690&quot;,&quot;field_6059870&quot;,&quot;field_450fc22&quot;,&quot;field_3e13d2d&quot;,&quot;field_0987804&quot;,&quot;field_44ca52e&quot;,&quot;field_8695799&quot;,&quot;field_991eecb&quot;,&quot;field_41881cb&quot;,&quot;field_5517eb1&quot;,&quot;field_7626cec&quot;,&quot;field_2e963e6&quot;,&quot;field_ac20a2d&quot;,&quot;field_74f03fe&quot;,&quot;field_b7867f2&quot;,&quot;field_dea18d0&quot;,&quot;field_5fec1c8&quot;,&quot;field_af6d7de&quot;,&quot;field_adadc2b&quot;,&quot;field_709ed2e&quot;,&quot;field_5476251&quot;,&quot;field_c9aff3d&quot;,&quot;field_bd5d6e4&quot;,&quot;field_cb72d97&quot;,&quot;field_fcb7991&quot;,&quot;field_55036ec&quot;,&quot;field_0197e95&quot;,&quot;field_4fbad83&quot;,&quot;field_402f6a1&quot;,&quot;field_8c586d0&quot;,&quot;field_be9c88e&quot;,&quot;field_910fb74&quot;,&quot;field_89862f4&quot;,&quot;field_0dfb862&quot;,&quot;field_5eb4a30&quot;,&quot;field_ffe487e&quot;,&quot;field_f84cdeb&quot;,&quot;field_52badca&quot;,&quot;field_40b8fdd&quot;,&quot;field_5543808&quot;,&quot;field_bbcce95&quot;,&quot;field_534d1b7&quot;,&quot;field_8eea62c&quot;,&quot;field_01186bb&quot;,&quot;field_cb94788&quot;,&quot;field_b02fe2f&quot;,&quot;field_42beda7&quot;,&quot;field_f578c40&quot;,&quot;field_452fcde&quot;,&quot;field_516811c&quot;,&quot;field_5125085&quot;,&quot;field_6c6aa42&quot;,&quot;field_2dcb222&quot;,&quot;field_3c95eef&quot;,&quot;field_70d43d1&quot;,&quot;field_c0f5bfa&quot;,&quot;field_134d1a9&quot;,&quot;field_2a12993&quot;,&quot;field_b158af1&quot;,&quot;field_53b13be&quot;,&quot;field_5311096&quot;,&quot;field_a32b514&quot;,&quot;field_7280410&quot;,&quot;field_a01450e&quot;,&quot;field_14a0556&quot;,&quot;field_9f18ddc&quot;,&quot;field_93c2fa0&quot;,&quot;field_48f178d&quot;,&quot;field_86bfddb&quot;,&quot;field_e913df7&quot;,&quot;field_49d1dcb&quot;,&quot;field_cb67248&quot;,&quot;field_bb3bce2&quot;,&quot;field_0c3c67f&quot;,&quot;field_c94b54f&quot;,&quot;field_47652b0&quot;,&quot;field_7d24076&quot;,&quot;field_383fcae&quot;,&quot;field_ab664ae&quot;,&quot;field_a6fc612&quot;,&quot;field_6d9d94c&quot;,&quot;field_1707ce0&quot;,&quot;arewoman&quot;,&quot;field_2d2e1a8&quot;,&quot;field_087e5e6&quot;,&quot;field_5abb864&quot;,&quot;field_728a7ca&quot;,&quot;field_93d1157&quot;,&quot;field_8faf4fa&quot;,&quot;field_e0cee9b&quot;,&quot;field_5a054b5&quot;,&quot;field_94e8164&quot;,&quot;field_e9125e9&quot;,&quot;field_ce869d6&quot;,&quot;field_aa991ec&quot;,&quot;field_4466a9d&quot;,&quot;field_9858297&quot;,&quot;field_b1a64fe&quot;,&quot;field_1e0573c&quot;,&quot;field_1d623b3&quot;,&quot;field_a386a54&quot;,&quot;field_5c93de3&quot;,&quot;field_bc82911&quot;,&quot;field_d961c8b&quot;,&quot;field_b9b207f&quot;,&quot;field_52e5114&quot;,&quot;field_6f23a34&quot;,&quot;field_a47beba&quot;,&quot;field_36bb935&quot;,&quot;field_b3594fb&quot;,&quot;field_0c3e9f6&quot;,&quot;field_d56281e&quot;,&quot;field_bad4cd0&quot;,&quot;field_b9cb42d&quot;,&quot;field_10cac73&quot;,&quot;field_9ef520c&quot;,&quot;field_9e8a886&quot;,&quot;field_4a29450&quot;,&quot;field_c9db448&quot;,&quot;field_b221253&quot;,&quot;field_f333cb4&quot;,&quot;field_7ea3b1b&quot;,&quot;field_2e30b3e&quot;,&quot;field_5167e8d&quot;,&quot;field_378a04a&quot;,&quot;field_fae3d4f&quot;,&quot;field_03be181&quot;]\" class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_57ed1c9 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Patient information\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-name elementor-col-20\">\n\t\t\t\t\t<small class=\"form-info1\"><i class=\"fa fa-exclamation-circle\"><\/i> This field is completed by the clinic<\/small>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c72d2ae elementor-col-80\">\n\t\t\t\t\t&nbsp;\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-patient elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-patient\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPaciente #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[patient]\" id=\"form-field-patient\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Paciente #\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-ss elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-ss\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSS#\/SIN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[ss]\" id=\"form-field-ss\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"SS#\/SIN\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-fecha elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fecha\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[fecha]\" id=\"form-field-fecha\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3242de1 elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3242de1\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3242de1]\" id=\"form-field-field_3242de1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_ba63340 elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba63340\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_ba63340]\" id=\"form-field-field_ba63340\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_92facb7 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_92facb7\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de casa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_92facb7]\" id=\"form-field-field_92facb7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono de casa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-adress_employer elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-adress_employer\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[adress_employer]\" id=\"form-field-adress_employer\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-city elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-city\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[city]\" id=\"form-field-city\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-state elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-state\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[state]\" id=\"form-field-state\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-zip elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-zip\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[zip]\" id=\"form-field-zip\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_56e3526 elementor-col-60 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_56e3526\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_56e3526]\" id=\"form-field-field_56e3526\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Correo electr\u00f3nico\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2e04a9f elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2e04a9f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono m\u00f3vil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2e04a9f]\" id=\"form-field-field_2e04a9f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono m\u00f3vil\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0f02a94 elementor-col-100\">\n\t\t\t\t\tMarque la casilla adecuada:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_bf6b69b elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bf6b69b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tStatus\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Minor\" id=\"form-field-field_bf6b69b-0\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-0\">Menor<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Single\" id=\"form-field-field_bf6b69b-1\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-1\">Soltero<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Married\" id=\"form-field-field_bf6b69b-2\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-2\">Casado<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Divorced\" id=\"form-field-field_bf6b69b-3\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-3\">Divorciado<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Widowed\" id=\"form-field-field_bf6b69b-4\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-4\">Viudo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Separated\" id=\"form-field-field_bf6b69b-5\" name=\"form_fields[field_bf6b69b]\" required=\"required\"> <label for=\"form-field-field_bf6b69b-5\">Separado<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4b28dff elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b28dff\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSi es estudiante, nombre de la escuela\/universidad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4b28dff]\" id=\"form-field-field_4b28dff\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Si es estudiante, nombre de la escuela\/universidad\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2deb87b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2deb87b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2deb87b]\" id=\"form-field-field_2deb87b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_075f5cc elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_075f5cc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_075f5cc]\" id=\"form-field-field_075f5cc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9b0f536 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9b0f536\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tHora\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Full time\" id=\"form-field-field_9b0f536-0\" name=\"form_fields[field_9b0f536]\"> <label for=\"form-field-field_9b0f536-0\">Tiempo completo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Part time\" id=\"form-field-field_9b0f536-1\" name=\"form_fields[field_9b0f536]\"> <label for=\"form-field-field_9b0f536-1\">Tiempo parcial<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fafeeac elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fafeeac\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPatient or parent\/Guardian's employer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fafeeac]\" id=\"form-field-field_fafeeac\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Patient or parent\/Guardian&#039;s employer\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_668fb80 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_668fb80\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_668fb80]\" id=\"form-field-field_668fb80\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ee3c94 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ee3c94\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ee3c94]\" id=\"form-field-field_3ee3c94\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_299286e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_299286e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_299286e]\" id=\"form-field-field_299286e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e5ac040 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e5ac040\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e5ac040]\" id=\"form-field-field_e5ac040\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_86c6449 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_86c6449\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_86c6449]\" id=\"form-field-field_86c6449\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_09b16dc elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_09b16dc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSpouse or parent\/Guardian's name\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_09b16dc]\" id=\"form-field-field_09b16dc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Spouse or parent\/Guardian&#039;s name\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8d5faed elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8d5faed\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEmpleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8d5faed]\" id=\"form-field-field_8d5faed\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Empleador\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_63ca89c elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_63ca89c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_63ca89c]\" id=\"form-field-field_63ca89c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fef81e2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fef81e2\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfA qui\u00e9n podemos dar las gracias por remitirle?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fef81e2]\" id=\"form-field-field_fef81e2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u00bfA qui\u00e9n podemos dar las gracias por remitirle?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a4a14e7 elementor-col-70 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a4a14e7\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPersona de contacto en caso de emergencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a4a14e7]\" id=\"form-field-field_a4a14e7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Persona de contacto en caso de emergencia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_72ead85 elementor-col-30 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_72ead85\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_72ead85]\" id=\"form-field-field_72ead85\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_85a2a0b elementor-col-100\">\n\t\t\t\t\t<h6 style=\"margin-bottom: 0;\">PACIENTE RESPONSABLE<\/h6>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7b7f24d elementor-col-66\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b7f24d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre de la persona responsable de esta cuenta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7b7f24d]\" id=\"form-field-field_7b7f24d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre de la persona responsable de esta cuenta\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b68c0a9 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b68c0a9\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b68c0a9]\" id=\"form-field-field_b68c0a9\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Relaci\u00f3n con el paciente\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7f9da96 elementor-col-66\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7f9da96\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7f9da96]\" id=\"form-field-field_7f9da96\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b9217ae elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b9217ae\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de casa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b9217ae]\" id=\"form-field-field_b9217ae\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono de casa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_bf2f7ef elementor-col-66\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bf2f7ef\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_bf2f7ef]\" id=\"form-field-field_bf2f7ef\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Correo electr\u00f3nico\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c767d58 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c767d58\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono m\u00f3vil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c767d58]\" id=\"form-field-field_c767d58\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono m\u00f3vil\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_41f2687 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_41f2687\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDriver's licence number\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_41f2687]\" id=\"form-field-field_41f2687\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Driver&#039;s licence number\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_e3bde48 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3bde48\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_e3bde48]\" id=\"form-field-field_e3bde48\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e7a5b4c elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e7a5b4c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tInstituci\u00f3n financiera\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e7a5b4c]\" id=\"form-field-field_e7a5b4c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Instituci\u00f3n financiera\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3cbee20 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3cbee20\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEmpleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3cbee20]\" id=\"form-field-field_3cbee20\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Empleador\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_44841fb elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_44841fb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_44841fb]\" id=\"form-field-field_44841fb\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7c8990f elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c8990f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSS#\/SIN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7c8990f]\" id=\"form-field-field_7c8990f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"SS#\/SIN\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c050482 elementor-col-60\">\n\t\t\t\t\tEsta persona es actualmente un paciente en nuestro consultorio?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1c24ef0 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c24ef0\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEsta persona es actualmente un paciente en nuestro consultorio?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1c24ef0-0\" name=\"form_fields[field_1c24ef0]\"> <label for=\"form-field-field_1c24ef0-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1c24ef0-1\" name=\"form_fields[field_1c24ef0]\"> <label for=\"form-field-field_1c24ef0-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_772df95 elementor-col-100\">\n\t\t\t\t\tPara su comodidad, ofrecemos los siguientes m\u00e9todos de pago. Marque la opci\u00f3n que prefiera. Pago completo en cada cita.\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_af1f278 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af1f278\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPara su comodidad, ofrecemos los siguientes m\u00e9todos de pago. Marque la opci\u00f3n que prefiera. Pago completo en cada cita.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Cash\" id=\"form-field-field_af1f278-0\" name=\"form_fields[field_af1f278]\" required=\"required\"> <label for=\"form-field-field_af1f278-0\">Dinero en efectivo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Personal Check\" id=\"form-field-field_af1f278-1\" name=\"form_fields[field_af1f278]\" required=\"required\"> <label for=\"form-field-field_af1f278-1\">Cheque personal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"VISA\" id=\"form-field-field_af1f278-2\" name=\"form_fields[field_af1f278]\" required=\"required\"> <label for=\"form-field-field_af1f278-2\">VISA<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"MasterCard\" id=\"form-field-field_af1f278-3\" name=\"form_fields[field_af1f278]\" required=\"required\"> <label for=\"form-field-field_af1f278-3\">MasterCard<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"I wish to discuss the office&#039;s payment policy\" id=\"form-field-field_af1f278-4\" name=\"form_fields[field_af1f278]\" required=\"required\"> <label for=\"form-field-field_af1f278-4\">Deseo discutir la pol\u00edtica de pago de la oficina.<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_ea3ee39 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Insurance information\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_956232b elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_956232b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre del asegurado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_956232b]\" id=\"form-field-field_956232b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre del asegurado\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-relationship elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-relationship\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[relationship]\" id=\"form-field-relationship\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Relaci\u00f3n con el paciente\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_2bca0c9 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2bca0c9\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_2bca0c9]\" id=\"form-field-field_2bca0c9\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e07af4c elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e07af4c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSS#\/SIN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e07af4c]\" id=\"form-field-field_e07af4c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"SS#\/SIN\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-fecha2 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fecha2\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[fecha2]\" id=\"form-field-fecha2\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0abdb1c elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0abdb1c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre del empleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0abdb1c]\" id=\"form-field-field_0abdb1c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre del empleador\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-union elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-union\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSindicato o local\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[union]\" id=\"form-field-union\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Sindicato o local\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-work_phone elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-work_phone\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[work_phone]\" id=\"form-field-work_phone\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cf5e3bc elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cf5e3bc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n del empleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cf5e3bc]\" id=\"form-field-field_cf5e3bc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n del empleador\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5c6b9c0 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5c6b9c0\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5c6b9c0]\" id=\"form-field-field_5c6b9c0\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_03a544c elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_03a544c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_03a544c]\" id=\"form-field-field_03a544c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_eee4356 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_eee4356\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_eee4356]\" id=\"form-field-field_eee4356\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurance_company elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurance_company\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCompa\u00f1\u00eda de seguros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurance_company]\" id=\"form-field-insurance_company\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Compa\u00f1\u00eda de seguros\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-group elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-group\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tGrupo #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[group]\" id=\"form-field-group\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Grupo #\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-policy elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-policy\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tP\u00f3liza\/ID #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[policy]\" id=\"form-field-policy\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"P\u00f3liza\/ID #\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_078ab4b elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_078ab4b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n de la compa\u00f1\u00eda de seguros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_078ab4b]\" id=\"form-field-field_078ab4b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n de la compa\u00f1\u00eda de seguros\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7b9e78f elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b9e78f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7b9e78f]\" id=\"form-field-field_7b9e78f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4973c26 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4973c26\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4973c26]\" id=\"form-field-field_4973c26\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_49c7d6f elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_49c7d6f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_49c7d6f]\" id=\"form-field-field_49c7d6f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_809790d elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_809790d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1nto es su deducible?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_809790d]\" id=\"form-field-field_809790d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u00bfCu\u00e1nto es su deducible?\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2dfb088 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2dfb088\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1nto has usado?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2dfb088]\" id=\"form-field-field_2dfb088\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u00bfCu\u00e1nto has usado?\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e3b2409 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e3b2409\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMax. beneficio anual\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e3b2409]\" id=\"form-field-field_e3b2409\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Max. beneficio anual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0b294af elementor-col-50\">\n\t\t\t\t\t\u00bfTIENE ALG\u00daN SEGURO ADICIONAL?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-extra elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-extra\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfTIENE ALG\u00daN SEGURO ADICIONAL?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-extra-0\" name=\"form_fields[extra]\" required=\"required\"> <label for=\"form-field-extra-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-extra-1\" name=\"form_fields[extra]\" required=\"required\"> <label for=\"form-field-extra-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a0e9d66 elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a0e9d66\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre del asegurado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a0e9d66]\" id=\"form-field-field_a0e9d66\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre del asegurado\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_74dbece elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_74dbece\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_74dbece]\" id=\"form-field-field_74dbece\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Relaci\u00f3n con el paciente\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_e22d640 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e22d640\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_e22d640]\" id=\"form-field-field_e22d640\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e429e76 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e429e76\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSS#\/SIN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e429e76]\" id=\"form-field-field_e429e76\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"SS#\/SIN\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_04fa567 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_04fa567\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha 2\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_04fa567]\" id=\"form-field-field_04fa567\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_515fa9b elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_515fa9b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre del empleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_515fa9b]\" id=\"form-field-field_515fa9b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre del empleador\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6bb19a8 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6bb19a8\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSindicato o local\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6bb19a8]\" id=\"form-field-field_6bb19a8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Sindicato o local\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e0d330e elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e0d330e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e0d330e]\" id=\"form-field-field_e0d330e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cacfa12 elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cacfa12\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n del empleador\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cacfa12]\" id=\"form-field-field_cacfa12\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n del empleador\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5b2400f elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5b2400f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5b2400f]\" id=\"form-field-field_5b2400f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_064d903 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_064d903\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_064d903]\" id=\"form-field-field_064d903\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_250d35c elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_250d35c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_250d35c]\" id=\"form-field-field_250d35c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3b98d99 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3b98d99\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCompa\u00f1\u00eda de seguros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3b98d99]\" id=\"form-field-field_3b98d99\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Compa\u00f1\u00eda de seguros\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ff376f4 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff376f4\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tGrupo #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ff376f4]\" id=\"form-field-field_ff376f4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Grupo #\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_091c3fc elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_091c3fc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tP\u00f3liza\/ID #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_091c3fc]\" id=\"form-field-field_091c3fc\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"P\u00f3liza\/ID #\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_56c0d7c elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_56c0d7c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n de la compa\u00f1\u00eda de seguros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_56c0d7c]\" id=\"form-field-field_56c0d7c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Direcci\u00f3n de la compa\u00f1\u00eda de seguros\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bcecc10 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bcecc10\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bcecc10]\" id=\"form-field-field_bcecc10\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0af3444 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0af3444\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEstado\/Provincia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0af3444]\" id=\"form-field-field_0af3444\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Estado\/Provincia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_338364e elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_338364e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_338364e]\" id=\"form-field-field_338364e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"C\u00f3digo postal\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1dd003b elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1dd003b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1nto es su deducible?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1dd003b]\" id=\"form-field-field_1dd003b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u00bfCu\u00e1nto es su deducible?\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_58d8a3c elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_58d8a3c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1nto has usado?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_58d8a3c]\" id=\"form-field-field_58d8a3c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"\u00bfCu\u00e1nto has usado?\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9be1222 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9be1222\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMax. beneficio anual\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9be1222]\" id=\"form-field-field_9be1222\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Max. beneficio anual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_7447e4a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Patient medical history\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3a6ff2c elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3a6ff2c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tM\u00e9dico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3a6ff2c]\" id=\"form-field-field_3a6ff2c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"M\u00e9dico\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_38fed77 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38fed77\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de oficina\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38fed77]\" id=\"form-field-field_38fed77\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Tel\u00e9fono de oficina\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_bfd9c44 elementor-col-33 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bfd9c44\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_bfd9c44]\" id=\"form-field-field_bfd9c44\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7ac29df elementor-col-60\">\n\t\t\t\t\t1. \u00bfEst\u00e1 recibiendo tratamiento m\u00e9dico ahora?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4ea1b61 elementor-col-40 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ea1b61\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t1. \u00bfEst\u00e1 recibiendo tratamiento m\u00e9dico ahora?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4ea1b61-0\" name=\"form_fields[field_4ea1b61]\" required=\"required\"> <label for=\"form-field-field_4ea1b61-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4ea1b61-1\" name=\"form_fields[field_4ea1b61]\" required=\"required\"> <label for=\"form-field-field_4ea1b61-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ca6d67f elementor-col-100\">\n\t\t\t\t\t2. \u00bfAlguna vez ha sido hospitalizado por alguna operaci\u00f3n quir\u00fargica o enfermedad grave en los \u00faltimos 5 a\u00f1os?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-hospitalized elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-hospitalized\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-hospitalized-0\" name=\"form_fields[hospitalized]\" required=\"required\"> <label for=\"form-field-hospitalized-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-hospitalized-1\" name=\"form_fields[hospitalized]\" required=\"required\"> <label for=\"form-field-hospitalized-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_c07df65 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c07df65\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tExplique\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_c07df65]\" id=\"form-field-field_c07df65\" rows=\"4\" placeholder=\"Explique\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d3f23bf elementor-col-80\">\n\t\t\t\t\t3. \u00bfEst\u00e1 tomando alg\u00fan medicamento, incluidos los de venta libre?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-medication elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medication\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t3. Are you taking any medication(s) including non-prescription medicine?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-medication-0\" name=\"form_fields[medication]\" required=\"required\"> <label for=\"form-field-medication-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-medication-1\" name=\"form_fields[medication]\" required=\"required\"> <label for=\"form-field-medication-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_06834de elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_06834de\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMedicamentos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_06834de]\" id=\"form-field-field_06834de\" rows=\"4\" placeholder=\"Medicamentos\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1f76dc7 elementor-col-80\">\n\t\t\t\t\t4. \u00bfHa tomado alguna vez Fen-Phen \/ Redux?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_730f92d elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_730f92d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t4. \u00bfHa tomado alguna vez Fen-Phen \/ Redux?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_730f92d-0\" name=\"form_fields[field_730f92d]\" required=\"required\"> <label for=\"form-field-field_730f92d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_730f92d-1\" name=\"form_fields[field_730f92d]\" required=\"required\"> <label for=\"form-field-field_730f92d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7d72066 elementor-col-80\">\n\t\t\t\t\t5. \u00bfHa tomado alguna vez Fosamax, Boniva, Actonel o alg\u00fan medicamento contra el c\u00e1ncer que contenga bisfosfonatos?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_300c1dd elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_300c1dd\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t5. \u00bfHa tomado alguna vez Fosamax, Boniva, Actonel o alg\u00fan medicamento contra el c\u00e1ncer que contenga bisfosfonatos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_300c1dd-0\" name=\"form_fields[field_300c1dd]\" required=\"required\"> <label for=\"form-field-field_300c1dd-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_300c1dd-1\" name=\"form_fields[field_300c1dd]\" required=\"required\"> <label for=\"form-field-field_300c1dd-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2c30b47 elementor-col-80\">\n\t\t\t\t\t6. \u00bfHa tomado alguna vez Viagra, Revatio, Cialis o Levitra en las \u00faltimas 24 horas?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ac55f62 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac55f62\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t6. \u00bfHa tomado alguna vez Viagra, Revatio, Cialis o Levitra en las \u00faltimas 24 horas?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_ac55f62-0\" name=\"form_fields[field_ac55f62]\" required=\"required\"> <label for=\"form-field-field_ac55f62-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_ac55f62-1\" name=\"form_fields[field_ac55f62]\" required=\"required\"> <label for=\"form-field-field_ac55f62-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a44509e elementor-col-80\">\n\t\t\t\t\t7. \u00bfUsa tabaco?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_8910343 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8910343\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t7. \u00bfUsa tabaco?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_8910343-0\" name=\"form_fields[field_8910343]\" required=\"required\"> <label for=\"form-field-field_8910343-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_8910343-1\" name=\"form_fields[field_8910343]\" required=\"required\"> <label for=\"form-field-field_8910343-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_65f4c95 elementor-col-80\">\n\t\t\t\t\t8. \u00bfUsa sustancias controladas?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_888ba96 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_888ba96\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t8. \u00bfUsa sustancias controladas?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_888ba96-0\" name=\"form_fields[field_888ba96]\" required=\"required\"> <label for=\"form-field-field_888ba96-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_888ba96-1\" name=\"form_fields[field_888ba96]\" required=\"required\"> <label for=\"form-field-field_888ba96-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_dc86106 elementor-col-100\">\n\t\t\t\t\t9. \u00bfTiene o ha tenido alguno de los siguientes?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a0ec057 elementor-col-30\">\n\t\t\t\t\tHipertensi\u00f3n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6e2572a elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6e2572a\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tHipertensi\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6e2572a-0\" name=\"form_fields[field_6e2572a]\" required=\"required\"> <label for=\"form-field-field_6e2572a-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6e2572a-1\" name=\"form_fields[field_6e2572a]\" required=\"required\"> <label for=\"form-field-field_6e2572a-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6392435 elementor-col-30\">\n\t\t\t\t\tInfarto de miocardio\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_d50f8fb elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d50f8fb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tInfarto de miocardio\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_d50f8fb-0\" name=\"form_fields[field_d50f8fb]\" required=\"required\"> <label for=\"form-field-field_d50f8fb-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_d50f8fb-1\" name=\"form_fields[field_d50f8fb]\" required=\"required\"> <label for=\"form-field-field_d50f8fb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_36ac690 elementor-col-30\">\n\t\t\t\t\tFiebre reum\u00e1tica\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6059870 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6059870\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFiebre reum\u00e1tica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6059870-0\" name=\"form_fields[field_6059870]\" required=\"required\"> <label for=\"form-field-field_6059870-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6059870-1\" name=\"form_fields[field_6059870]\" required=\"required\"> <label for=\"form-field-field_6059870-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_450fc22 elementor-col-30\">\n\t\t\t\t\tTobillos hinchados\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3e13d2d elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3e13d2d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTobillos hinchados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3e13d2d-0\" name=\"form_fields[field_3e13d2d]\" required=\"required\"> <label for=\"form-field-field_3e13d2d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3e13d2d-1\" name=\"form_fields[field_3e13d2d]\" required=\"required\"> <label for=\"form-field-field_3e13d2d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0987804 elementor-col-30\">\n\t\t\t\t\tDesmayos \/ convulsiones\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_44ca52e elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_44ca52e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDesmayos \/ convulsiones\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_44ca52e-0\" name=\"form_fields[field_44ca52e]\" required=\"required\"> <label for=\"form-field-field_44ca52e-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_44ca52e-1\" name=\"form_fields[field_44ca52e]\" required=\"required\"> <label for=\"form-field-field_44ca52e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8695799 elementor-col-30\">\n\t\t\t\t\tAsma\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_991eecb elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_991eecb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tAsma\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_991eecb-0\" name=\"form_fields[field_991eecb]\" required=\"required\"> <label for=\"form-field-field_991eecb-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_991eecb-1\" name=\"form_fields[field_991eecb]\" required=\"required\"> <label for=\"form-field-field_991eecb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_41881cb elementor-col-30\">\n\t\t\t\t\tPresi\u00f3n arterial baja\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5517eb1 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5517eb1\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tPresi\u00f3n arterial baja\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5517eb1-0\" name=\"form_fields[field_5517eb1]\" required=\"required\"> <label for=\"form-field-field_5517eb1-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5517eb1-1\" name=\"form_fields[field_5517eb1]\" required=\"required\"> <label for=\"form-field-field_5517eb1-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7626cec elementor-col-30\">\n\t\t\t\t\tEpilepsia \/ convulsiones\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_2e963e6 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2e963e6\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEpilepsia \/ convulsiones\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_2e963e6-0\" name=\"form_fields[field_2e963e6]\" required=\"required\"> <label for=\"form-field-field_2e963e6-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_2e963e6-1\" name=\"form_fields[field_2e963e6]\" required=\"required\"> <label for=\"form-field-field_2e963e6-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ac20a2d elementor-col-30\">\n\t\t\t\t\tLeucemia\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_74f03fe elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_74f03fe\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tLeucemia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_74f03fe-0\" name=\"form_fields[field_74f03fe]\" required=\"required\"> <label for=\"form-field-field_74f03fe-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_74f03fe-1\" name=\"form_fields[field_74f03fe]\" required=\"required\"> <label for=\"form-field-field_74f03fe-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b7867f2 elementor-col-30\">\n\t\t\t\t\tDiabetes\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_dea18d0 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dea18d0\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDiabetes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_dea18d0-0\" name=\"form_fields[field_dea18d0]\" required=\"required\"> <label for=\"form-field-field_dea18d0-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_dea18d0-1\" name=\"form_fields[field_dea18d0]\" required=\"required\"> <label for=\"form-field-field_dea18d0-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5fec1c8 elementor-col-30\">\n\t\t\t\t\tEnfermedades renales\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_af6d7de elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_af6d7de\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEnfermedades renales\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_af6d7de-0\" name=\"form_fields[field_af6d7de]\" required=\"required\"> <label for=\"form-field-field_af6d7de-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_af6d7de-1\" name=\"form_fields[field_af6d7de]\" required=\"required\"> <label for=\"form-field-field_af6d7de-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_adadc2b elementor-col-30\">\n\t\t\t\t\tSIDA o infecci\u00f3n por VIH\n\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_709ed2e elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_709ed2e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSIDA o infecci\u00f3n por VIH\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_709ed2e-0\" name=\"form_fields[field_709ed2e]\" required=\"required\"> <label for=\"form-field-field_709ed2e-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_709ed2e-1\" name=\"form_fields[field_709ed2e]\" required=\"required\"> <label for=\"form-field-field_709ed2e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5476251 elementor-col-30\">\n\t\t\t\t\tProblema de tiroides\n\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c9aff3d elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c9aff3d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tProblema de tiroides\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c9aff3d-0\" name=\"form_fields[field_c9aff3d]\" required=\"required\"> <label for=\"form-field-field_c9aff3d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c9aff3d-1\" name=\"form_fields[field_c9aff3d]\" required=\"required\"> <label for=\"form-field-field_c9aff3d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bd5d6e4 elementor-col-30\">\n\t\t\t\t\tEnfermedad del coraz\u00f3n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cb72d97 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb72d97\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEnfermedad del coraz\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_cb72d97-0\" name=\"form_fields[field_cb72d97]\" required=\"required\"> <label for=\"form-field-field_cb72d97-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_cb72d97-1\" name=\"form_fields[field_cb72d97]\" required=\"required\"> <label for=\"form-field-field_cb72d97-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_fcb7991 elementor-col-30\">\n\t\t\t\t\tMarcapasos card\u00edaco\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_55036ec elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_55036ec\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tMarcapasos card\u00edaco\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_55036ec-0\" name=\"form_fields[field_55036ec]\" required=\"required\"> <label for=\"form-field-field_55036ec-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_55036ec-1\" name=\"form_fields[field_55036ec]\" required=\"required\"> <label for=\"form-field-field_55036ec-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0197e95 elementor-col-30\">\n\t\t\t\t\tSoplo card\u00edaco\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4fbad83 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4fbad83\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tSoplo card\u00edaco\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4fbad83-0\" name=\"form_fields[field_4fbad83]\" required=\"required\"> <label for=\"form-field-field_4fbad83-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4fbad83-1\" name=\"form_fields[field_4fbad83]\" required=\"required\"> <label for=\"form-field-field_4fbad83-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_402f6a1 elementor-col-30\">\n\t\t\t\t\tAngina de pecho\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_8c586d0 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8c586d0\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tAngina de pecho\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_8c586d0-0\" name=\"form_fields[field_8c586d0]\" required=\"required\"> <label for=\"form-field-field_8c586d0-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_8c586d0-1\" name=\"form_fields[field_8c586d0]\" required=\"required\"> <label for=\"form-field-field_8c586d0-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_be9c88e elementor-col-30\">\n\t\t\t\t\tCansado con frecuencia\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_910fb74 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_910fb74\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCansado con frecuencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_910fb74-0\" name=\"form_fields[field_910fb74]\" required=\"required\"> <label for=\"form-field-field_910fb74-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_910fb74-1\" name=\"form_fields[field_910fb74]\" required=\"required\"> <label for=\"form-field-field_910fb74-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_89862f4 elementor-col-30\">\n\t\t\t\t\tAnemia\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0dfb862 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0dfb862\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tAnemia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_0dfb862-0\" name=\"form_fields[field_0dfb862]\" required=\"required\"> <label for=\"form-field-field_0dfb862-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_0dfb862-1\" name=\"form_fields[field_0dfb862]\" required=\"required\"> <label for=\"form-field-field_0dfb862-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5eb4a30 elementor-col-30\">\n\t\t\t\t\tEnfisema\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ffe487e elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ffe487e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEnfisema\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_ffe487e-0\" name=\"form_fields[field_ffe487e]\" required=\"required\"> <label for=\"form-field-field_ffe487e-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_ffe487e-1\" name=\"form_fields[field_ffe487e]\" required=\"required\"> <label for=\"form-field-field_ffe487e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f84cdeb elementor-col-30\">\n\t\t\t\t\tC\u00e1ncer\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_52badca elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_52badca\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tC\u00e1ncer\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_52badca-0\" name=\"form_fields[field_52badca]\" required=\"required\"> <label for=\"form-field-field_52badca-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_52badca-1\" name=\"form_fields[field_52badca]\" required=\"required\"> <label for=\"form-field-field_52badca-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_40b8fdd elementor-col-30\">\n\t\t\t\t\tArtritis\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5543808 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5543808\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tArtritis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5543808-0\" name=\"form_fields[field_5543808]\" required=\"required\"> <label for=\"form-field-field_5543808-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5543808-1\" name=\"form_fields[field_5543808]\" required=\"required\"> <label for=\"form-field-field_5543808-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bbcce95 elementor-col-30\">\n\t\t\t\t\tReemplazo o implante de articulaci\u00f3n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_534d1b7 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_534d1b7\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tReemplazo o implante de articulaci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_534d1b7-0\" name=\"form_fields[field_534d1b7]\" required=\"required\"> <label for=\"form-field-field_534d1b7-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_534d1b7-1\" name=\"form_fields[field_534d1b7]\" required=\"required\"> <label for=\"form-field-field_534d1b7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8eea62c elementor-col-30\">\n\t\t\t\t\tHepatitis \/ ictericia\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_01186bb elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_01186bb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tHepatitis \/ ictericia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_01186bb-0\" name=\"form_fields[field_01186bb]\" required=\"required\"> <label for=\"form-field-field_01186bb-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_01186bb-1\" name=\"form_fields[field_01186bb]\" required=\"required\"> <label for=\"form-field-field_01186bb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_cb94788 elementor-col-30\">\n\t\t\t\t\tEnfermedad de transmisi\u00f3n sexual\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b02fe2f elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b02fe2f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEnfermedad de transmisi\u00f3n sexual\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b02fe2f-0\" name=\"form_fields[field_b02fe2f]\" required=\"required\"> <label for=\"form-field-field_b02fe2f-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b02fe2f-1\" name=\"form_fields[field_b02fe2f]\" required=\"required\"> <label for=\"form-field-field_b02fe2f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_42beda7 elementor-col-30\">\n\t\t\t\t\tProblemas de est\u00f3mago \/ \u00falceras\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_f578c40 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f578c40\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tProblemas de est\u00f3mago \/ \u00falceras\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_f578c40-0\" name=\"form_fields[field_f578c40]\" required=\"required\"> <label for=\"form-field-field_f578c40-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_f578c40-1\" name=\"form_fields[field_f578c40]\" required=\"required\"> <label for=\"form-field-field_f578c40-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_452fcde elementor-col-30\">\n\t\t\t\t\tDolores en el pecho\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_516811c elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_516811c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tDolores en el pecho\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_516811c-0\" name=\"form_fields[field_516811c]\" required=\"required\"> <label for=\"form-field-field_516811c-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_516811c-1\" name=\"form_fields[field_516811c]\" required=\"required\"> <label for=\"form-field-field_516811c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5125085 elementor-col-30\">\n\t\t\t\t\tF\u00e1cilmente sin aliento\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6c6aa42 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6c6aa42\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tF\u00e1cilmente sin aliento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6c6aa42-0\" name=\"form_fields[field_6c6aa42]\" required=\"required\"> <label for=\"form-field-field_6c6aa42-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6c6aa42-1\" name=\"form_fields[field_6c6aa42]\" required=\"required\"> <label for=\"form-field-field_6c6aa42-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2dcb222 elementor-col-30\">\n\t\t\t\t\tCarrera\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3c95eef elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c95eef\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCarrera\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3c95eef-0\" name=\"form_fields[field_3c95eef]\" required=\"required\"> <label for=\"form-field-field_3c95eef-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3c95eef-1\" name=\"form_fields[field_3c95eef]\" required=\"required\"> <label for=\"form-field-field_3c95eef-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_70d43d1 elementor-col-30\">\n\t\t\t\t\tFiebre del heno \/ Alergias\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c0f5bfa elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c0f5bfa\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFiebre del heno \/ Alergias\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c0f5bfa-0\" name=\"form_fields[field_c0f5bfa]\" required=\"required\"> <label for=\"form-field-field_c0f5bfa-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c0f5bfa-1\" name=\"form_fields[field_c0f5bfa]\" required=\"required\"> <label for=\"form-field-field_c0f5bfa-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_134d1a9 elementor-col-30\">\n\t\t\t\t\tTuberculosis\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_2a12993 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2a12993\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTuberculosis\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_2a12993-0\" name=\"form_fields[field_2a12993]\" required=\"required\"> <label for=\"form-field-field_2a12993-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_2a12993-1\" name=\"form_fields[field_2a12993]\" required=\"required\"> <label for=\"form-field-field_2a12993-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b158af1 elementor-col-30\">\n\t\t\t\t\tTerapia de radiaci\u00f3n\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_53b13be elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_53b13be\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tTerapia de radiaci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_53b13be-0\" name=\"form_fields[field_53b13be]\" required=\"required\"> <label for=\"form-field-field_53b13be-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_53b13be-1\" name=\"form_fields[field_53b13be]\" required=\"required\"> <label for=\"form-field-field_53b13be-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5311096 elementor-col-30\">\n\t\t\t\t\tGlaucoma\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a32b514 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a32b514\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tGlaucoma\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a32b514-0\" name=\"form_fields[field_a32b514]\" required=\"required\"> <label for=\"form-field-field_a32b514-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a32b514-1\" name=\"form_fields[field_a32b514]\" required=\"required\"> <label for=\"form-field-field_a32b514-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7280410 elementor-col-30\">\n\t\t\t\t\tP\u00e9rdida de peso reciente\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a01450e elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a01450e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tP\u00e9rdida de peso reciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a01450e-0\" name=\"form_fields[field_a01450e]\" required=\"required\"> <label for=\"form-field-field_a01450e-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a01450e-1\" name=\"form_fields[field_a01450e]\" required=\"required\"> <label for=\"form-field-field_a01450e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_14a0556 elementor-col-30\">\n\t\t\t\t\tEnfermedad del higado\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9f18ddc elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9f18ddc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tEnfermedad del higado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_9f18ddc-0\" name=\"form_fields[field_9f18ddc]\" required=\"required\"> <label for=\"form-field-field_9f18ddc-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_9f18ddc-1\" name=\"form_fields[field_9f18ddc]\" required=\"required\"> <label for=\"form-field-field_9f18ddc-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_93c2fa0 elementor-col-30\">\n\t\t\t\t\tProblemas del coraz\u00f3n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_48f178d elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_48f178d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tProblemas del coraz\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_48f178d-0\" name=\"form_fields[field_48f178d]\" required=\"required\"> <label for=\"form-field-field_48f178d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_48f178d-1\" name=\"form_fields[field_48f178d]\" required=\"required\"> <label for=\"form-field-field_48f178d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_86bfddb elementor-col-30\">\n\t\t\t\t\tProblemas respiratorios\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e913df7 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e913df7\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tProblemas respiratorios\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_e913df7-0\" name=\"form_fields[field_e913df7]\" required=\"required\"> <label for=\"form-field-field_e913df7-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_e913df7-1\" name=\"form_fields[field_e913df7]\" required=\"required\"> <label for=\"form-field-field_e913df7-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_49d1dcb elementor-col-30\">\n\t\t\t\t\tProlapso de la v\u00e1lvula mitral\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cb67248 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cb67248\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tProlapso de la v\u00e1lvula mitral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_cb67248-0\" name=\"form_fields[field_cb67248]\" required=\"required\"> <label for=\"form-field-field_cb67248-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_cb67248-1\" name=\"form_fields[field_cb67248]\" required=\"required\"> <label for=\"form-field-field_cb67248-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_bb3bce2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bb3bce2\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tOtros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_bb3bce2]\" id=\"form-field-field_bb3bce2\" rows=\"3\" placeholder=\"Otros\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0c3c67f elementor-col-50\">\n\t\t\t\t\t10. \u00bfUsa lentes de contacto?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c94b54f elementor-col-50 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c94b54f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t10. \u00bfUsa lentes de contacto?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c94b54f-0\" name=\"form_fields[field_c94b54f]\" required=\"required\"> <label for=\"form-field-field_c94b54f-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c94b54f-1\" name=\"form_fields[field_c94b54f]\" required=\"required\"> <label for=\"form-field-field_c94b54f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_47652b0 elementor-col-100\">\n\t\t\t\t\t11. \u00bfEs al\u00e9rgico o ha tenido alguna reacci\u00f3n a lo siguiente?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7d24076 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7d24076\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t11. \u00bfEs al\u00e9rgico o ha tenido alguna reacci\u00f3n a lo siguiente?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_7d24076-0\" name=\"form_fields[field_7d24076]\" required=\"required\"> <label for=\"form-field-field_7d24076-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_7d24076-1\" name=\"form_fields[field_7d24076]\" required=\"required\"> <label for=\"form-field-field_7d24076-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_383fcae elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Local Anesthetics (e.g. Novocain)\" id=\"form-field-field_383fcae-0\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-0\">Anest\u00e9sicos locales (p. Ej., Novoca\u00edna)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Penicillin or any Other Antibiotics\" id=\"form-field-field_383fcae-1\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-1\">Penicilina o cualquier otro antibi\u00f3tico<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sulfa Drugs\" id=\"form-field-field_383fcae-2\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-2\">Drogas sulfa<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Barbiturates\" id=\"form-field-field_383fcae-3\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-3\">Barbit\u00faricos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sedatives\" id=\"form-field-field_383fcae-4\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-4\">Sedantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"lodine\" id=\"form-field-field_383fcae-5\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-5\">Yodo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aspirin\" id=\"form-field-field_383fcae-6\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-6\">Aspirina<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Any Metals (e.g. nickel, mercury, etc.)\" id=\"form-field-field_383fcae-7\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-7\">Cualquier metal (por ejemplo, n\u00edquel, mercurio, etc.)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Latex Rubber\" id=\"form-field-field_383fcae-8\" name=\"form_fields[field_383fcae][]\"> <label for=\"form-field-field_383fcae-8\">Goma de l\u00e1tex<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_ab664ae elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ab664ae\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tOtros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_ab664ae]\" id=\"form-field-field_ab664ae\" rows=\"3\" placeholder=\"Otros (por favor enumere)\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a6fc612 elementor-col-80\">\n\t\t\t\t\t12. \u00bfTiene tos persistente o carraspeo no asociado con una enfermedad conocida (que dura m\u00e1s de 3 semanas)?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6d9d94c elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d9d94c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6d9d94c-0\" name=\"form_fields[field_6d9d94c]\" required=\"required\"> <label for=\"form-field-field_6d9d94c-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6d9d94c-1\" name=\"form_fields[field_6d9d94c]\" required=\"required\"> <label for=\"form-field-field_6d9d94c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1707ce0 elementor-col-100\">\n\t\t\t\t\t13. Solo mujeres. \u00bfEres mujer?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-arewoman elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-arewoman\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfAre you a woman?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-arewoman-0\" name=\"form_fields[arewoman]\" required=\"required\"> <label for=\"form-field-arewoman-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-arewoman-1\" name=\"form_fields[arewoman]\" required=\"required\"> <label for=\"form-field-arewoman-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2d2e1a8 elementor-col-80\">\n\t\t\t\t\t\u00bfEst\u00e1 embarazada o cree que puede estarlo?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_087e5e6 elementor-col-20 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_087e5e6\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1 embarazada o cree que puede estarlo?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_087e5e6-0\" name=\"form_fields[field_087e5e6]\" required=\"required\"> <label for=\"form-field-field_087e5e6-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_087e5e6-1\" name=\"form_fields[field_087e5e6]\" required=\"required\"> <label for=\"form-field-field_087e5e6-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5abb864 elementor-col-80\">\n\t\t\t\t\t\u00bfEst\u00e1s amamantando?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_728a7ca elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_728a7ca\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1s amamantando?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_728a7ca-0\" name=\"form_fields[field_728a7ca]\"> <label for=\"form-field-field_728a7ca-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_728a7ca-1\" name=\"form_fields[field_728a7ca]\"> <label for=\"form-field-field_728a7ca-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_93d1157 elementor-col-80\">\n\t\t\t\t\t\u00bfEst\u00e1 tomando anticonceptivos orales?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_8faf4fa elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8faf4fa\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1 tomando anticonceptivos orales?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_8faf4fa-0\" name=\"form_fields[field_8faf4fa]\"> <label for=\"form-field-field_8faf4fa-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_8faf4fa-1\" name=\"form_fields[field_8faf4fa]\"> <label for=\"form-field-field_8faf4fa-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e0cee9b elementor-col-100\">\n\t\t\t\t\t<h6 style=\"margin-bottom: 0;\">HOSTORIAN DENTAL DEL PACIENTE<\/h6>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5a054b5 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5a054b5\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre del dentista anterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5a054b5]\" id=\"form-field-field_5a054b5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre del dentista anterior\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_94e8164 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_94e8164\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tUbicaci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_94e8164]\" id=\"form-field-field_94e8164\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ubicaci\u00f3n\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_e9125e9 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e9125e9\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tFecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_e9125e9]\" id=\"form-field-field_e9125e9\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_ce869d6 elementor-col-80\">\n\t\t\t\t\t1. \u00bfLe sangran las enc\u00edas mientras se cepilla o usa hilo dental?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_aa991ec elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aa991ec\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t1. \u00bfLe sangran las enc\u00edas mientras se cepilla o usa hilo dental?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_aa991ec-0\" name=\"form_fields[field_aa991ec]\"> <label for=\"form-field-field_aa991ec-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_aa991ec-1\" name=\"form_fields[field_aa991ec]\"> <label for=\"form-field-field_aa991ec-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4466a9d elementor-col-80\">\n\t\t\t\t\t2. \u00bfSon sus dientes sensibles a l\u00edquidos \/ alimentos calientes o fr\u00edos?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9858297 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9858297\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t2. \u00bfSon sus dientes sensibles a l\u00edquidos \/ alimentos calientes o fr\u00edos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_9858297-0\" name=\"form_fields[field_9858297]\"> <label for=\"form-field-field_9858297-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_9858297-1\" name=\"form_fields[field_9858297]\"> <label for=\"form-field-field_9858297-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_b1a64fe elementor-col-80\">\n\t\t\t\t\t3. \u00bfSus dientes son sensibles a los l\u00edquidos \/ alimentos agridulces?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1e0573c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1e0573c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t3. \u00bfSus dientes son sensibles a los l\u00edquidos \/ alimentos agridulces?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1e0573c-0\" name=\"form_fields[field_1e0573c]\"> <label for=\"form-field-field_1e0573c-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1e0573c-1\" name=\"form_fields[field_1e0573c]\"> <label for=\"form-field-field_1e0573c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1d623b3 elementor-col-80\">\n\t\t\t\t\t4. \u00bfSiente dolor en alguno de sus dientes?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a386a54 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a386a54\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t4. \u00bfSiente dolor en alguno de sus dientes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a386a54-0\" name=\"form_fields[field_a386a54]\"> <label for=\"form-field-field_a386a54-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a386a54-1\" name=\"form_fields[field_a386a54]\"> <label for=\"form-field-field_a386a54-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5c93de3 elementor-col-80\">\n\t\t\t\t\t5. \u00bfTiene llagas o bultos en la boca o cerca de ella?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_bc82911 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bc82911\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t5. \u00bfTiene llagas o bultos en la boca o cerca de ella?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_bc82911-0\" name=\"form_fields[field_bc82911]\"> <label for=\"form-field-field_bc82911-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_bc82911-1\" name=\"form_fields[field_bc82911]\"> <label for=\"form-field-field_bc82911-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_d961c8b elementor-col-80\">\n\t\t\t\t\t6. \u00bfHa tenido alguna lesi\u00f3n en la cabeza, el cuello o la mand\u00edbula?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b9b207f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b9b207f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t6. \u00bfHa tenido alguna lesi\u00f3n en la cabeza, el cuello o la mand\u00edbula?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b9b207f-0\" name=\"form_fields[field_b9b207f]\"> <label for=\"form-field-field_b9b207f-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b9b207f-1\" name=\"form_fields[field_b9b207f]\"> <label for=\"form-field-field_b9b207f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_52e5114 elementor-col-100\">\n\t\t\t\t\t7. \u00bfAlguna vez ha experimentado alguno de los siguientes problemas en la mand\u00edbula?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6f23a34 elementor-col-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6f23a34\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t7. \u00bfAlguna vez ha experimentado alguno de los siguientes problemas en la mand\u00edbula?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6f23a34-0\" name=\"form_fields[field_6f23a34]\" required=\"required\"> <label for=\"form-field-field_6f23a34-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6f23a34-1\" name=\"form_fields[field_6f23a34]\" required=\"required\"> <label for=\"form-field-field_6f23a34-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_a47beba elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Clicking\" id=\"form-field-field_a47beba-0\" name=\"form_fields[field_a47beba][]\"> <label for=\"form-field-field_a47beba-0\">Haciendo clic<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pain (joint, ear, side of face)\" id=\"form-field-field_a47beba-1\" name=\"form_fields[field_a47beba][]\"> <label for=\"form-field-field_a47beba-1\">Dolor (articulaci\u00f3n, o\u00eddo, lado de la cara)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Difficulty in opening or closing\" id=\"form-field-field_a47beba-2\" name=\"form_fields[field_a47beba][]\"> <label for=\"form-field-field_a47beba-2\">Dificultad para abrir o cerrar<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Difficulty in chewing\" id=\"form-field-field_a47beba-3\" name=\"form_fields[field_a47beba][]\"> <label for=\"form-field-field_a47beba-3\">Dificultad para masticar<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_36bb935 elementor-col-80\">\n\t\t\t\t\t8. \u00bfTiene dolores de cabeza frecuentes?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b3594fb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b3594fb\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t8. \u00bfTiene dolores de cabeza frecuentes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b3594fb-0\" name=\"form_fields[field_b3594fb]\"> <label for=\"form-field-field_b3594fb-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b3594fb-1\" name=\"form_fields[field_b3594fb]\"> <label for=\"form-field-field_b3594fb-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0c3e9f6 elementor-col-80\">\n\t\t\t\t\t9. \u00bfAprieta o rechina los dientes?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_d56281e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d56281e\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t9. \u00bfAprieta o rechina los dientes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_d56281e-0\" name=\"form_fields[field_d56281e]\"> <label for=\"form-field-field_d56281e-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_d56281e-1\" name=\"form_fields[field_d56281e]\"> <label for=\"form-field-field_d56281e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bad4cd0 elementor-col-80\">\n\t\t\t\t\t10. \u00bfSe muerde los labios o las mejillas con frecuencia?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b9cb42d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b9cb42d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t10. \u00bfSe muerde los labios o las mejillas con frecuencia?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b9cb42d-0\" name=\"form_fields[field_b9cb42d]\"> <label for=\"form-field-field_b9cb42d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b9cb42d-1\" name=\"form_fields[field_b9cb42d]\"> <label for=\"form-field-field_b9cb42d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_10cac73 elementor-col-80\">\n\t\t\t\t\t11. \u00bfHa tenido extracciones dif\u00edciles en el pasado?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_9ef520c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9ef520c\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t11. \u00bfHa tenido extracciones dif\u00edciles en el pasado?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_9ef520c-0\" name=\"form_fields[field_9ef520c]\"> <label for=\"form-field-field_9ef520c-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_9ef520c-1\" name=\"form_fields[field_9ef520c]\"> <label for=\"form-field-field_9ef520c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9e8a886 elementor-col-80\">\n\t\t\t\t\t12. \u00bfHa tenido alguna vez sangrado prolongado despu\u00e9s de las extracciones?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4a29450 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a29450\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t12. \u00bfHa tenido alguna vez sangrado prolongado despu\u00e9s de las extracciones?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4a29450-0\" name=\"form_fields[field_4a29450]\"> <label for=\"form-field-field_4a29450-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4a29450-1\" name=\"form_fields[field_4a29450]\"> <label for=\"form-field-field_4a29450-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_c9db448 elementor-col-80\">\n\t\t\t\t\t13. \u00bfHa tenido alg\u00fan tratamiento de ortodoncia?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b221253 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b221253\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t13. \u00bfHa tenido alg\u00fan tratamiento de ortodoncia?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b221253-0\" name=\"form_fields[field_b221253]\"> <label for=\"form-field-field_b221253-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b221253-1\" name=\"form_fields[field_b221253]\"> <label for=\"form-field-field_b221253-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_f333cb4 elementor-col-80\">\n\t\t\t\t\t14. \u00bfUsa dentaduras postizas o parciales?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_7ea3b1b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7ea3b1b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t14. \u00bfUsa dentaduras postizas o parciales?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_7ea3b1b-0\" name=\"form_fields[field_7ea3b1b]\"> <label for=\"form-field-field_7ea3b1b-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_7ea3b1b-1\" name=\"form_fields[field_7ea3b1b]\"> <label for=\"form-field-field_7ea3b1b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2e30b3e elementor-col-80\">\n\t\t\t\t\t15. \u00bfHa recibido alguna vez instrucciones de higiene bucal sobre el cuidado de sus dientes y enc\u00edas?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5167e8d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5167e8d\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5167e8d-0\" name=\"form_fields[field_5167e8d]\"> <label for=\"form-field-field_5167e8d-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5167e8d-1\" name=\"form_fields[field_5167e8d]\"> <label for=\"form-field-field_5167e8d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_378a04a elementor-col-80\">\n\t\t\t\t\t16. \u00bfTe gusta tu sonrisa?\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_fae3d4f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fae3d4f\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\t16. \u00bfTe gusta tu sonrisa?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_fae3d4f-0\" name=\"form_fields[field_fae3d4f]\"> <label for=\"form-field-field_fae3d4f-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_fae3d4f-1\" name=\"form_fields[field_fae3d4f]\"> <label for=\"form-field-field_fae3d4f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_03be181 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_03be181\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LceFRYiAAAAAJWB-yEwVMsAdhepsJCa31WFeLLc\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-md\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-5e43da0\" data-id=\"5e43da0\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-99f31d9 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"99f31d9\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;sticky&quot;:&quot;top&quot;,&quot;sticky_on&quot;:[&quot;desktop&quot;],&quot;sticky_offset&quot;:80,&quot;sticky_parent&quot;:&quot;yes&quot;,&quot;sticky_effects_offset&quot;:0,&quot;sticky_anchor_link_offset&quot;:0}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-b3eedda\" data-id=\"b3eedda\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e11b3d6 animated-slow elementor-invisible elementor-widget elementor-widget-template\" data-id=\"e11b3d6\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeIn&quot;}\" data-widget_type=\"template.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-template\">\n\t\t\t\t\t<div data-elementor-type=\"section\" data-elementor-id=\"562\" class=\"elementor elementor-562\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-d12e275 animated-slow elementor-section-boxed elementor-section-height-default elementor-section-height-default elementor-invisible\" data-id=\"d12e275\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;animation&quot;:&quot;fadeIn&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-392ad680\" data-id=\"392ad680\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-47b77eb1 elementor-widget elementor-widget-heading\" data-id=\"47b77eb1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Solicitud de cita r\u00e1pida<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3df5f08e elementor-widget elementor-widget-text-editor\" data-id=\"3df5f08e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"translation-block\">Las citas no se confirman hasta que la oficina se comunica para confirmar su informaci\u00f3n. Si tiene alguna pregunta, <a href=\"https:\/\/econdental.org\/es\/contacto\/\" target=\"_self\">cont\u00e1ctenos aqu\u00ed<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3f724a2d elementor-button-align-stretch elementor-widget elementor-widget-form\" data-id=\"3f724a2d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" id=\"quick_appointment\" name=\"Quick appointment\" aria-label=\"Cita r\u00e1pida\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"562\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3f724a2d\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Econ Dental - Family, cosmetic &amp; implant dentistry\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"10\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre completo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe tu nombre\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-telephone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-telephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de contacto\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[telephone]\" id=\"form-field-telephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe tu tel\u00e9fono de contacto\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe tu correo electr\u00f3nico\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-date elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-date\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSelecciona fecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[date]\" id=\"form-field-date\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"Fecha\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-time elementor-field-group elementor-column elementor-field-group-time elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-time\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSelecciona hora\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"time\" name=\"form_fields[time]\" id=\"form-field-time\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-time-field\" placeholder=\"Hora\" required=\"required\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_2397b49 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_2397b49]\" id=\"form-field-field_2397b49\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_2397b49\">He le\u00eddo y acepto las <a href=\"https:\/\/econdental.org\/es\/privacy-policy\/\" target=\"_blank\">pol\u00edticas de privacidad<\/a><\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-recaptcha_v3 elementor-field-group elementor-column elementor-field-group-field_b3e3230 elementor-col-100 recaptcha_v3-bottomright\">\n\t\t\t\t\t<div class=\"elementor-field\" id=\"form-field-field_b3e3230\"><div class=\"elementor-g-recaptcha\" data-sitekey=\"6LceFRYiAAAAAJWB-yEwVMsAdhepsJCa31WFeLLc\" data-type=\"v3\" data-action=\"Form\" data-badge=\"bottomright\" data-size=\"invisible\"><\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-82a084f elementor-align-left elementor-invisible elementor-widget elementor-widget-button\" data-id=\"82a084f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;fadeInUp&quot;,&quot;_animation_delay&quot;:500}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-md\" href=\"https:\/\/econdental.org\/es\/financing\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-chevron-right\"><\/i>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Solicitar cr\u00e9dito<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Patient Forms Thank you in advance for the trust you have placed in our office. \u00a0Below is a downloadable version for new patients forms. \u00a0Please print them, fill them out and bring them with you to your first appointment. \u00a0This will allow us more time to devote to your dental needs. Please call the office [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":14,"menu_order":11,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"tags":[],"class_list":["post-39","page","type-page","status-publish","hentry"],"blocksy_meta":{"styles_descriptor":{"styles":{"desktop":"","tablet":"","mobile":""},"google_fonts":[]}},"_links":{"self":[{"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/pages\/39","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/comments?post=39"}],"version-history":[{"count":6,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/pages\/39\/revisions"}],"predecessor-version":[{"id":1432,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/pages\/39\/revisions\/1432"}],"up":[{"embeddable":true,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/pages\/14"}],"wp:attachment":[{"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/media?parent=39"}],"wp:term":[{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/econdental.org\/es\/wp-json\/wp\/v2\/tags?post=39"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}