{"id":22,"date":"2021-01-20T19:57:25","date_gmt":"2021-01-20T19:57:25","guid":{"rendered":"https:\/\/fernandezgoico.com\/?page_id=22"},"modified":"2024-03-12T22:57:34","modified_gmt":"2024-03-12T22:57:34","slug":"form","status":"publish","type":"page","link":"https:\/\/fernandezgoico.com\/en\/form\/","title":{"rendered":"Request an Evaluation"},"content":{"rendered":"<section class=\"l-section wpb_row height_small\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row type_default valign_top\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><div class=\"w-image align_center\"><a title=\"Home\" href=\"https:\/\/fernandezgoico.com\/\" aria-label=\"Link\" class=\"w-image-h\"><img decoding=\"async\" src=\"https:\/\/fernandezgoico.com\/wp-content\/uploads\/2021\/01\/logo-fg.svg\" class=\"attachment-full size-full\" alt=\"\" \/><\/a><\/div><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row us_custom_2a0907cb height_small width_full color_secondary\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row type_default valign_top\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><h2 class=\"w-post-elm post_title align_center entry-title color_link_inherit\">Solicita una Evaluaci\u00f3n<\/h2><\/div><\/div><\/div><\/div><\/div><\/section><section class=\"l-section wpb_row us_custom_647fc389 height_auto\"><div class=\"l-section-h i-cf\"><div class=\"g-cols vc_row type_default valign_top\"><div class=\"vc_col-sm-12 wpb_column vc_column_container\"><div class=\"vc_column-inner us_custom_57aa99bf\"><div class=\"wpb_wrapper\"><div class=\"w-separator size_medium\"><\/div><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_1' id='gform_1'  action='\/en\/wp-json\/wp\/v2\/pages\/22#gf_1' data-formid='1' novalidate>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_gray' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_gray percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_182\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 style=\"text-align: center; color: #151b54;\">Para verificar si es candidato\/a a la cirug\u00eda que desea, por favor complete este formulario con sus datos y adjunte fotos de las \u00e1reas a tratar. Ya sea en consulta presencial o virtual con el Dr. Fern\u00e1ndez, es importante que sea honesto\/a y preciso\/a en sus respuestas. Su seguridad y el \u00e9xito del procedimiento son nuestra prioridad.<\/h3><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Sexo<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_66'>\n\t\t\t<li class='gchoice gchoice_1_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='F' checked='checked' id='choice_1_66_0'    \/>\n\t\t\t\t<label for='choice_1_66_0' id='label_1_66_0' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='M'  id='choice_1_66_1'    \/>\n\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-name gfield--input-type-name gf_left_third capital gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nombre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_16'>\n                            \n                            <span id='input_1_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_1_16_3' value=''   aria-required='true'   placeholder='Nombre(s)'  \/>\n                                                    <label for='input_1_16_3' class='gform-field-label gform-field-label--type-sub '>Nombre(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_1_16_6' value=''   aria-required='true'   placeholder='Apellido(s)'  \/>\n                                                    <label for='input_1_16_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'><span class='gform-field-label__text'>Fecha de nacimiento<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_1_67'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_67'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_67' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_67' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_67' aria-label='Fecha de nacimiento: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_166\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_166'><span class='gform-field-label__text'>Edad<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_166' id='input_1_166' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_135\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half capital gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_135'><span class='gform-field-label__text'>Nacionalidad<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_1_135' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_171'><span class='gform-field-label__text'>Profesi\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_1_171' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Tipo de documento de identidad<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_154'>\n\t\t\t<li class='gchoice gchoice_1_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='C\u00e9dula' checked='checked' id='choice_1_154_0'    \/>\n\t\t\t\t<label for='choice_1_154_0' id='label_1_154_0' class='gform-field-label gform-field-label--type-inline'>C\u00e9dula<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='Pasaporte'  id='choice_1_154_1'    \/>\n\t\t\t\t<label for='choice_1_154_1' id='label_1_154_1' class='gform-field-label gform-field-label--type-inline'>Pasaporte<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_137\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_137'><span class='gform-field-label__text'>No. de c\u00e9dula<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_1_137' type='text' value='' class='medium'    placeholder='999-9999999-9' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"999-9999999-9\"\/><\/div><\/li><li id=\"field_1_138\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_138'><span class='gform-field-label__text'>No. de pasaporte<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_1_138' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-email gfield--input-type-email gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_1_17' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'><span class='gform-field-label__text'>M\u00f3vil \/ Whatsapp<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_19' id='input_1_19' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/li><li id=\"field_1_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_right_third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_70'><span class='gform-field-label__text'>Instagram user:<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Direcci\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_state has_country ginput_container_address gform-grid-row' id='input_1_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_1_23_1' value=''   placeholder='Calle, Ave.' aria-required='true'    \/>\n                                        <label for='input_1_23_1' id='input_1_23_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_23_4_container' >\n                                        <input type='text' name='input_23.4' id='input_1_23_4' value=''     placeholder='Estado\/Provincia' aria-required='true'    \/>\n                                        <label for='input_1_23_4' id='input_1_23_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_23_6_container' >\n                                        <select name='input_23.6' id='input_1_23_6'   aria-required='true'    ><option value='' >Pa\u00eds<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_1_23_6' id='input_1_23_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfViajar\u00eda desde otra ciudad o pa\u00eds para la cirug\u00eda?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_208'>\n\t\t\t<li class='gchoice gchoice_1_208_0'>\n\t\t\t\t<input name='input_208' type='radio' value='Si'  id='choice_1_208_0'    \/>\n\t\t\t\t<label for='choice_1_208_0' id='label_1_208_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_208_1'>\n\t\t\t\t<input name='input_208' type='radio' value='No'  id='choice_1_208_1'    \/>\n\t\t\t\t<label for='choice_1_208_1' id='label_1_208_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Elija c\u00f3mo desea consultar<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_163'>Nota: En todos los casos, el total de la consulta se abona al total cotizado.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_163'>\n\t\t\t<li class='gchoice gchoice_1_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='Evaluaci\u00f3n Presencial'  id='choice_1_163_0'    \/>\n\t\t\t\t<label for='choice_1_163_0' id='label_1_163_0' class='gform-field-label gform-field-label--type-inline'>Evaluaci\u00f3n Presencial<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='Evaluaci\u00f3n por fotos'  id='choice_1_163_1'    \/>\n\t\t\t\t<label for='choice_1_163_1' id='label_1_163_1' class='gform-field-label gform-field-label--type-inline'>Evaluaci\u00f3n por fotos<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_163_2'>\n\t\t\t\t<input name='input_163' type='radio' value='Videollamada con el Doctor'  id='choice_1_163_2'    \/>\n\t\t\t\t<label for='choice_1_163_2' id='label_1_163_2' class='gform-field-label gform-field-label--type-inline'>Videollamada con el Doctor<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_131\" class=\"gfield gfield--type-select gfield--input-type-select gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_131'><span class='gform-field-label__text'>Motivo Consulta<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_131' id='input_1_131' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Cicatriz Inest\u00e9tica' >Cicatriz Inest\u00e9tica<\/option><option value='Evaluaci\u00f3n Abdomen' >Evaluaci\u00f3n Abdomen<\/option><option value='Evaluaci\u00f3n Corporal' >Evaluaci\u00f3n Corporal<\/option><option value='Evaluaci\u00f3n Facial' >Evaluaci\u00f3n Facial<\/option><option value='Evaluaci\u00f3n General' >Evaluaci\u00f3n General<\/option><option value='Evaluaci\u00f3n Gl\u00fateos' >Evaluaci\u00f3n Gl\u00fateos<\/option><option value='Evaluaci\u00f3n Regi\u00f3n \u00cdntima' >Evaluaci\u00f3n Regi\u00f3n \u00cdntima<\/option><option value='Evaluaci\u00f3n Senos' >Evaluaci\u00f3n Senos<\/option><option value='Revisi\u00f3n de Cirug\u00eda Anterior' >Revisi\u00f3n de Cirug\u00eda Anterior<\/option><option value='Otro' >Otro<\/option><\/select><\/div><\/li><li id=\"field_1_124\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_124'><span class='gform-field-label__text'>Otro motivo de consulta<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_1_124' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_209\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_209'><span class='gform-field-label__text'>\u00bfCu\u00e1l es su principal objetivo o expectativa de la cirug\u00eda?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_1_209' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_207\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_207'><span class='gform-field-label__text'>\u00bfCu\u00e1l es la fecha que prefiere para la cirug\u00eda?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_207'>Seleccione una fecha deseada, tomando en cuenta que esta NO CUENTA  COMO RESERVA de cirug\u00eda. <\/div><div class='ginput_container ginput_container_text'><input name='input_207' id='input_1_207' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_207\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_164\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_164'><span class='gform-field-label__text'>\u00bfQui\u00e9n le recomend\u00f3 al Dr. Fern\u00e1ndez o c\u00f3mo nos encontr\u00f3?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_164' id='input_1_164' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_133\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Procedimientos de inter\u00e9s  (Marque todas las que apliquen)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_133'><li class='gchoice gchoice_1_133_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.1' type='checkbox'  value='Botox'  id='choice_1_133_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_1' id='label_1_133_1' class='gform-field-label gform-field-label--type-inline'>Botox<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.2' type='checkbox'  value='Rellenos Faciales'  id='choice_1_133_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_2' id='label_1_133_2' class='gform-field-label gform-field-label--type-inline'>Rellenos Faciales<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.3' type='checkbox'  value='Rinoplast\u00eda'  id='choice_1_133_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_3' id='label_1_133_3' class='gform-field-label gform-field-label--type-inline'>Rinoplast\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.4' type='checkbox'  value='Otoplast\u00eda (Cirug\u00eda de Orejas)'  id='choice_1_133_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_4' id='label_1_133_4' class='gform-field-label gform-field-label--type-inline'>Otoplast\u00eda (Cirug\u00eda de Orejas)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.5' type='checkbox'  value='Genioplast\u00eda (Cirug\u00eda de Ment\u00f3n)'  id='choice_1_133_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_5' id='label_1_133_5' class='gform-field-label gform-field-label--type-inline'>Genioplast\u00eda (Cirug\u00eda de Ment\u00f3n)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.6' type='checkbox'  value='Blefaroplast\u00eda (Cirug\u00eda de P\u00e1rpados)'  id='choice_1_133_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_6' id='label_1_133_6' class='gform-field-label gform-field-label--type-inline'>Blefaroplast\u00eda (Cirug\u00eda de P\u00e1rpados)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.7' type='checkbox'  value='Liposucci\u00f3n Papada'  id='choice_1_133_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_7' id='label_1_133_7' class='gform-field-label gform-field-label--type-inline'>Liposucci\u00f3n Papada<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.8' type='checkbox'  value='Lifting de Cuello'  id='choice_1_133_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_8' id='label_1_133_8' class='gform-field-label gform-field-label--type-inline'>Lifting de Cuello<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.9' type='checkbox'  value='Lifting Facial'  id='choice_1_133_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_9' id='label_1_133_9' class='gform-field-label gform-field-label--type-inline'>Lifting Facial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.11' type='checkbox'  value='Bichectom\u00eda'  id='choice_1_133_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_11' id='label_1_133_11' class='gform-field-label gform-field-label--type-inline'>Bichectom\u00eda<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.12' type='checkbox'  value='Aumento de Senos'  id='choice_1_133_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_12' id='label_1_133_12' class='gform-field-label gform-field-label--type-inline'>Aumento de Senos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.13' type='checkbox'  value='Levantamiento de senos'  id='choice_1_133_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_13' id='label_1_133_13' class='gform-field-label gform-field-label--type-inline'>Levantamiento de senos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.14' type='checkbox'  value='Reducci\u00f3n de Senos'  id='choice_1_133_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_14' id='label_1_133_14' class='gform-field-label gform-field-label--type-inline'>Reducci\u00f3n de Senos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.15' type='checkbox'  value='Cambio \u00f3 retiro de implantes'  id='choice_1_133_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_15' id='label_1_133_15' class='gform-field-label gform-field-label--type-inline'>Cambio \u00f3 retiro de implantes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.16' type='checkbox'  value='Liposucci\u00f3n general vaser'  id='choice_1_133_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_16' id='label_1_133_16' class='gform-field-label gform-field-label--type-inline'>Liposucci\u00f3n general vaser<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.17' type='checkbox'  value='Liposucci\u00f3n brazos'  id='choice_1_133_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_17' id='label_1_133_17' class='gform-field-label gform-field-label--type-inline'>Liposucci\u00f3n brazos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.18' type='checkbox'  value='Liposucci\u00f3n muslos'  id='choice_1_133_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_18' id='label_1_133_18' class='gform-field-label gform-field-label--type-inline'>Liposucci\u00f3n muslos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.19' type='checkbox'  value='Definici\u00f3n Abdominal Vaser'  id='choice_1_133_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_19' id='label_1_133_19' class='gform-field-label gform-field-label--type-inline'>Definici\u00f3n Abdominal Vaser<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.21' type='checkbox'  value='Lipoinyecci\u00f3n Gl\u00fateos (Bbl)'  id='choice_1_133_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_21' id='label_1_133_21' class='gform-field-label gform-field-label--type-inline'>Lipoinyecci\u00f3n Gl\u00fateos (Bbl)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.22' type='checkbox'  value='Abdominoplast\u00eda (con refuerzo de musculatura abdominal)'  id='choice_1_133_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_22' id='label_1_133_22' class='gform-field-label gform-field-label--type-inline'>Abdominoplast\u00eda (con refuerzo de musculatura abdominal)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.23' type='checkbox'  value='MiniAbdominoplast\u00eda (sin reparaci\u00f3n de musculatura abdominal)'  id='choice_1_133_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_23' id='label_1_133_23' class='gform-field-label gform-field-label--type-inline'>MiniAbdominoplast\u00eda (sin reparaci\u00f3n de musculatura abdominal)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.24' type='checkbox'  value='Correcci\u00f3n de cicatrices'  id='choice_1_133_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_24' id='label_1_133_24' class='gform-field-label gform-field-label--type-inline'>Correcci\u00f3n de cicatrices<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.25' type='checkbox'  value='Reparaci\u00f3n Hernia'  id='choice_1_133_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_25' id='label_1_133_25' class='gform-field-label gform-field-label--type-inline'>Reparaci\u00f3n Hernia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.26' type='checkbox'  value='Ginecomast\u00eda (Reducci\u00f3n gl\u00e1ndulas mamrias masculina)'  id='choice_1_133_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_26' id='label_1_133_26' class='gform-field-label gform-field-label--type-inline'>Ginecomast\u00eda (Reducci\u00f3n gl\u00e1ndulas mamrias masculina)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.27' type='checkbox'  value='Lifting Brazos'  id='choice_1_133_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_27' id='label_1_133_27' class='gform-field-label gform-field-label--type-inline'>Lifting Brazos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.28' type='checkbox'  value='Lifting de Muslos'  id='choice_1_133_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_28' id='label_1_133_28' class='gform-field-label gform-field-label--type-inline'>Lifting de Muslos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.29' type='checkbox'  value='J-Plasma\/Renuvion'  id='choice_1_133_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_29' id='label_1_133_29' class='gform-field-label gform-field-label--type-inline'>J-Plasma\/Renuvion<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_133_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_133.31' type='checkbox'  value='Otro'  id='choice_1_133_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_133_31' id='label_1_133_31' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_134\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_134'><span class='gform-field-label__text'>Otro procedimiento de inter\u00e9s<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_1_134' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Favor especifique la raz\u00f3n de cambio o retiro de implantes<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_144'>\n\t\t\t<li class='gchoice gchoice_1_144_0'>\n\t\t\t\t<input name='input_144' type='radio' value='Ruptura o encapsulamiento del implante'  id='choice_1_144_0'    \/>\n\t\t\t\t<label for='choice_1_144_0' id='label_1_144_0' class='gform-field-label gform-field-label--type-inline'>Ruptura o encapsulamiento del implante<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_144_1'>\n\t\t\t\t<input name='input_144' type='radio' value='Cambiar el tama\u00f1o de los implantes o mejorar aspecto est\u00e9tico'  id='choice_1_144_1'    \/>\n\t\t\t\t<label for='choice_1_144_1' id='label_1_144_1' class='gform-field-label gform-field-label--type-inline'>Cambiar el tama\u00f1o de los implantes o mejorar aspecto est\u00e9tico<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_144_2'>\n\t\t\t\t<input name='input_144' type='radio' value='Mis implantes tienen m\u00e1s de 10 a\u00f1os y se me inform\u00f3 deb\u00eda cambiarlos'  id='choice_1_144_2'    \/>\n\t\t\t\t<label for='choice_1_144_2' id='label_1_144_2' class='gform-field-label gform-field-label--type-inline'>Mis implantes tienen m\u00e1s de 10 a\u00f1os y se me inform\u00f3 deb\u00eda cambiarlos<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_1_173' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Pr\u00f3ximo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-173' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_71\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">DATOS CL\u00cdNICOS<\/h2><\/li><li id=\"field_1_169\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_169'><span class='gform-field-label__text'>Peso actual  (lbs)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_169' id='input_1_169' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_168\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_168'><span class='gform-field-label__text'>Estatura (pie, pulg.)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_168' id='input_1_168' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='48' >4&#039;0<\/option><option value='49' >4\u20191<\/option><option value='50' >4\u20192<\/option><option value='51' >4\u20193<\/option><option value='52' >4\u20194<\/option><option value='53' >4\u20195<\/option><option value='54' >4\u20196<\/option><option value='55' >4\u20197<\/option><option value='56' >4\u20198<\/option><option value='57' >4\u20199<\/option><option value='58' >4\u201910<\/option><option value='59' >4\u201911<\/option><option value='60' >5&#039;0<\/option><option value='61' >5\u20191<\/option><option value='62' >5\u20192<\/option><option value='63' >5\u20193<\/option><option value='64' >5\u20194<\/option><option value='65' >5\u20195<\/option><option value='66' >5\u20196<\/option><option value='67' >5\u20197<\/option><option value='68' >5\u20198<\/option><option value='69' >5\u20199<\/option><option value='70' >5\u201910<\/option><option value='71' >5\u201911<\/option><option value='72' >6&#039;0<\/option><option value='73' >6&#039;1<\/option><option value='74' >6&#039;2<\/option><option value='75' >6&#039;3<\/option><option value='76' >6&#039;4<\/option><option value='77' >6&#039;5<\/option><option value='78' >6&#039;6<\/option><option value='79' >6&#039;7<\/option><option value='80' >6&#039;8<\/option><option value='81' >6&#039;9<\/option><option value='82' >6&#039;10<\/option><option value='83' >6&#039;11<\/option><option value='84' >7&#039;0<\/option><\/select><\/div><\/li><li id=\"field_1_170\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_170'><span class='gform-field-label__text'>IMC<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_170' id='input_1_170' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_1_172\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h4 class=\"alertadoc\">El Dr. Fern\u00e1ndez no realiza procedimientos quir\u00fargicos en pacientes con un IMC (\u00edndice de masa corporal) igual o mayor a 30.<br \/>En este caso, recomienda alcanzar un peso m\u00e1s saludable y solicitar la cita en ese momento para una evaluaci\u00f3n m\u00e1s objetiva.<\/h4>\n\n<\/li><li id=\"field_1_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_2col field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>\u00bfSufre o ha sufrido de alguna de estas enfermedades o condiciones de salud? Marcque todas las que apliquen.<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_51'><li class='gchoice gchoice_1_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='COVID-19'  id='choice_1_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>COVID-19<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Diabetes'  id='choice_1_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_2' id='label_1_51_2' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Enfermedades del Coraz\u00f3n'  id='choice_1_51_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_3' id='label_1_51_3' class='gform-field-label gform-field-label--type-inline'>Enfermedades del Coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='Falcemia'  id='choice_1_51_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_4' id='label_1_51_4' class='gform-field-label gform-field-label--type-inline'>Falcemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='Portador(a) de Falcemia'  id='choice_1_51_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_5' id='label_1_51_5' class='gform-field-label gform-field-label--type-inline'>Portador(a) de Falcemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='Tromboflebitis'  id='choice_1_51_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_6' id='label_1_51_6' class='gform-field-label gform-field-label--type-inline'>Tromboflebitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='Trombosis venosa'  id='choice_1_51_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_7' id='label_1_51_7' class='gform-field-label gform-field-label--type-inline'>Trombosis venosa<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.8' type='checkbox'  value='Varices'  id='choice_1_51_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_8' id='label_1_51_8' class='gform-field-label gform-field-label--type-inline'>Varices<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.9' type='checkbox'  value='Enfermedad Psiqui\u00e1trica'  id='choice_1_51_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_9' id='label_1_51_9' class='gform-field-label gform-field-label--type-inline'>Enfermedad Psiqui\u00e1trica<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.11' type='checkbox'  value='Constipaci\u00f3n (estre\u00f1imiento)'  id='choice_1_51_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_11' id='label_1_51_11' class='gform-field-label gform-field-label--type-inline'>Constipaci\u00f3n (estre\u00f1imiento)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.12' type='checkbox'  value='Presi\u00f3n arterial'  id='choice_1_51_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_12' id='label_1_51_12' class='gform-field-label gform-field-label--type-inline'>Presi\u00f3n arterial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.13' type='checkbox'  value='Sangrado'  id='choice_1_51_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_13' id='label_1_51_13' class='gform-field-label gform-field-label--type-inline'>Sangrado<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.14' type='checkbox'  value='Tiroides'  id='choice_1_51_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_14' id='label_1_51_14' class='gform-field-label gform-field-label--type-inline'>Tiroides<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.15' type='checkbox'  value='Asma'  id='choice_1_51_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_15' id='label_1_51_15' class='gform-field-label gform-field-label--type-inline'>Asma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.16' type='checkbox'  value='Historia de anemia'  id='choice_1_51_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_16' id='label_1_51_16' class='gform-field-label gform-field-label--type-inline'>Historia de anemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.17' type='checkbox'  value='Hepatitis A'  id='choice_1_51_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_17' id='label_1_51_17' class='gform-field-label gform-field-label--type-inline'>Hepatitis A<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.18' type='checkbox'  value='Hepatitis B'  id='choice_1_51_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_18' id='label_1_51_18' class='gform-field-label gform-field-label--type-inline'>Hepatitis B<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.19' type='checkbox'  value='Hepatitis C'  id='choice_1_51_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_19' id='label_1_51_19' class='gform-field-label gform-field-label--type-inline'>Hepatitis C<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.21' type='checkbox'  value='HIV (Sida)'  id='choice_1_51_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_21' id='label_1_51_21' class='gform-field-label gform-field-label--type-inline'>HIV (Sida)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.22' type='checkbox'  value='Condici\u00f3n Ginec\u00f3logica'  id='choice_1_51_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_22' id='label_1_51_22' class='gform-field-label gform-field-label--type-inline'>Condici\u00f3n Ginec\u00f3logica (polipos, miomas uterinos, ovario poliquistico, quiste ov\u00e1rico, quiste mamario)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.23' type='checkbox'  value='Otra'  id='choice_1_51_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_23' id='label_1_51_23' class='gform-field-label gform-field-label--type-inline'>Otra<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'><span class='gform-field-label__text'>Favor especifique su problema de salud<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_210\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_210'><span class='gform-field-label__text'>Favor especifique su enfermedad psiqui\u00e1trica<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_210' id='input_1_210' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_165\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>\u00bfAlguien en su familia cercana (padres, hermanos, hijos) ha sido diagnosticado o tiene antecedentes de alguna de las siguientes condiciones de salud? Por favor, marque todas las que correspondan:<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_165'><li class='gchoice gchoice_1_165_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.1' type='checkbox'  value='Diabetes tipo 2'  id='choice_1_165_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_1' id='label_1_165_1' class='gform-field-label gform-field-label--type-inline'>Diabetes tipo 2<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.2' type='checkbox'  value='Hipertensi\u00f3n arterial'  id='choice_1_165_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_2' id='label_1_165_2' class='gform-field-label gform-field-label--type-inline'>Hipertensi\u00f3n arterial<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.3' type='checkbox'  value='Enfermedades card\u00edacas'  id='choice_1_165_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_3' id='label_1_165_3' class='gform-field-label gform-field-label--type-inline'>Enfermedades card\u00edacas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.4' type='checkbox'  value='C\u00e1ncer'  id='choice_1_165_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_4' id='label_1_165_4' class='gform-field-label gform-field-label--type-inline'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.5' type='checkbox'  value='Enfermedades autoinmunes'  id='choice_1_165_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_5' id='label_1_165_5' class='gform-field-label gform-field-label--type-inline'>Enfermedades autoinmunes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.6' type='checkbox'  value='Trastornos psiqui\u00e1tricos'  id='choice_1_165_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_6' id='label_1_165_6' class='gform-field-label gform-field-label--type-inline'>Trastornos psiqui\u00e1tricos<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.7' type='checkbox'  value='Enfermedades neurol\u00f3gicas'  id='choice_1_165_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_7' id='label_1_165_7' class='gform-field-label gform-field-label--type-inline'>Enfermedades neurol\u00f3gicas<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.8' type='checkbox'  value='Otros'  id='choice_1_165_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_8' id='label_1_165_8' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_165_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.9' type='checkbox'  value='No, nadie'  id='choice_1_165_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_165_9' id='label_1_165_9' class='gform-field-label gform-field-label--type-inline'>No, nadie<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_79'><span class='gform-field-label__text'>Otros antecedentes familaires<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline pagebreak gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma alg\u00fan medicamento o suplemento regularmente (para la presi\u00f3n, anitdepresivos, prote\u00edna, suplementos para p\u00e9rdida de peso, vitaminas)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_45'>\n\t\t\t<li class='gchoice gchoice_1_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='S\u00ed'  id='choice_1_45_0'    \/>\n\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_1_45_1'    \/>\n\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'><span class='gform-field-label__text'>Especifique los medicamentos \/ suplementos que toma<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_155\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa sufrido Tromboembolismo Pulmonar?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_155'>\n\t\t\t<li class='gchoice gchoice_1_155_0'>\n\t\t\t\t<input name='input_155' type='radio' value='S\u00ed'  id='choice_1_155_0'    \/>\n\t\t\t\t<label for='choice_1_155_0' id='label_1_155_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_155_1'>\n\t\t\t\t<input name='input_155' type='radio' value='No'  id='choice_1_155_1'    \/>\n\t\t\t\t<label for='choice_1_155_1' id='label_1_155_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_98'><span class='gform-field-label__text'>\u00bfCu\u00e1ndo sufriste Tromboembolismo Pulmonar?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_1_98' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_123\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_123'><span class='gform-field-label__text'>Tipo de Sangre<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_1_123' class='small gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='A' >A<\/option><option value='A+' >A+<\/option><option value='A-' >A-<\/option><option value='AB' >AB<\/option><option value='AB+' >AB+<\/option><option value='AB-' >AB-<\/option><option value='B' >B<\/option><option value='B+' >B+<\/option><option value='B-' >B-<\/option><option value='O' >O<\/option><option value='O+' >O+<\/option><option value='O-' >O-<\/option><\/select><\/div><\/li><li id=\"field_1_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTiene o ha tenido hijo(s)?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_156'>\n\t\t\t<li class='gchoice gchoice_1_156_0'>\n\t\t\t\t<input name='input_156' type='radio' value='S\u00ed'  id='choice_1_156_0'    \/>\n\t\t\t\t<label for='choice_1_156_0' id='label_1_156_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_156_1'>\n\t\t\t\t<input name='input_156' type='radio' value='No'  id='choice_1_156_1'    \/>\n\t\t\t\t<label for='choice_1_156_1' id='label_1_156_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_157\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfC\u00f3mo fue su \u00faltimo parto?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_157'>\n\t\t\t<li class='gchoice gchoice_1_157_0'>\n\t\t\t\t<input name='input_157' type='radio' value='Parto Natural'  id='choice_1_157_0'    \/>\n\t\t\t\t<label for='choice_1_157_0' id='label_1_157_0' class='gform-field-label gform-field-label--type-inline'>Parto Natural<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_157_1'>\n\t\t\t\t<input name='input_157' type='radio' value='Ces\u00e1rea'  id='choice_1_157_1'    \/>\n\t\t\t\t<label for='choice_1_157_1' id='label_1_157_1' class='gform-field-label gform-field-label--type-inline'>Ces\u00e1rea<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_186\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfSu \u00faltimo parto fue hace 1 a\u00f1o o menos?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_186'>\n\t\t\t<li class='gchoice gchoice_1_186_0'>\n\t\t\t\t<input name='input_186' type='radio' value='S\u00ed'  id='choice_1_186_0'    \/>\n\t\t\t\t<label for='choice_1_186_0' id='label_1_186_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_186_1'>\n\t\t\t\t<input name='input_186' type='radio' value='No'  id='choice_1_186_1'    \/>\n\t\t\t\t<label for='choice_1_186_1' id='label_1_186_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_73'><span class='gform-field-label__text'>Fecha de su \u00faltimo parto<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_1_73'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_73'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_1_73' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_1_73' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_1_73' aria-label='Fecha de su \u00faltimo parto: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/li><li id=\"field_1_185\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 style=\"color:#da0001;\">En caso de no estar amamantando, debe haber esperado 6 meses postparto para evaluarse.<\/h3>\n<\/li><li id=\"field_1_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa amamantado a su hij(a) en los \u00faltimos 6 meses?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_187'>\n\t\t\t<li class='gchoice gchoice_1_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='S\u00ed'  id='choice_1_187_0'    \/>\n\t\t\t\t<label for='choice_1_187_0' id='label_1_187_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_1_187_1'    \/>\n\t\t\t\t<label for='choice_1_187_1' id='label_1_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_211\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_211'><span class='gform-field-label__text'>Fecha en que suspendi\u00f3 lactancia<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_211' id='input_1_211' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_188\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 style=\"color:#da0001;\">Debe haber suspendido la lactancia al menos 6 meses antes de la evaluaci\u00f3n.<\/h3>\n<\/li><li id=\"field_1_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1s embarazada actualmente?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_183'>\n\t\t\t<li class='gchoice gchoice_1_183_0'>\n\t\t\t\t<input name='input_183' type='radio' value='S\u00ed'  id='choice_1_183_0'    \/>\n\t\t\t\t<label for='choice_1_183_0' id='label_1_183_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_183_1'>\n\t\t\t\t<input name='input_183' type='radio' value='No'  id='choice_1_183_1'    \/>\n\t\t\t\t<label for='choice_1_183_1' id='label_1_183_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_184\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_184'><span class='gform-field-label__text'>Semanas de gestaci\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_184' id='input_1_184' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Semana 1' >Semana 1<\/option><option value='Semana 2' >Semana 2<\/option><option value='Semana 3' >Semana 3<\/option><option value='Semana 4' >Semana 4<\/option><option value='Semana 5' >Semana 5<\/option><option value='Semana 6' >Semana 6<\/option><option value='Semana 7' >Semana 7<\/option><option value='Semana 8' >Semana 8<\/option><option value='Semana 9' >Semana 9<\/option><option value='Semana 10' >Semana 10<\/option><option value='Semana 11' >Semana 11<\/option><option value='Semana 12' >Semana 12<\/option><option value='Semana 13' >Semana 13<\/option><option value='Semana 14' >Semana 14<\/option><option value='Semana 15' >Semana 15<\/option><option value='Semana 16' >Semana 16<\/option><option value='Semana 17' >Semana 17<\/option><option value='Semana 18' >Semana 18<\/option><option value='Semana 19' >Semana 19<\/option><option value='Semana 20' >Semana 20<\/option><option value='Semana 21' >Semana 21<\/option><option value='Semana 22' >Semana 22<\/option><option value='Semana 23' >Semana 23<\/option><option value='Semana 24' >Semana 24<\/option><option value='Semana 25' >Semana 25<\/option><option value='Semana 26' >Semana 26<\/option><option value='Semana 27' >Semana 27<\/option><option value='Semana 28' >Semana 28<\/option><option value='Semana 29' >Semana 29<\/option><option value='Semana 30' >Semana 30<\/option><option value='Semana 31' >Semana 31<\/option><option value='Semana 32' >Semana 32<\/option><option value='Semana 33' >Semana 33<\/option><option value='Semana 34' >Semana 34<\/option><option value='Semana 35' >Semana 35<\/option><option value='Semana 36' >Semana 36<\/option><option value='Semana 37' >Semana 37<\/option><option value='Semana 38' >Semana 38<\/option><option value='Semana 39' >Semana 39<\/option><option value='Semana 40' >Semana 40<\/option><option value='Semana 41' >Semana 41<\/option><option value='Semana 42' >Semana 42<\/option><option value='Semana 43' >Semana 43<\/option><\/select><\/div><\/li><li id=\"field_1_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfPlanea tener (m\u00e1s) hijos?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_158'>\n\t\t\t<li class='gchoice gchoice_1_158_0'>\n\t\t\t\t<input name='input_158' type='radio' value='S\u00ed'  id='choice_1_158_0'    \/>\n\t\t\t\t<label for='choice_1_158_0' id='label_1_158_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_158_1'>\n\t\t\t\t<input name='input_158' type='radio' value='No'  id='choice_1_158_1'    \/>\n\t\t\t\t<label for='choice_1_158_1' id='label_1_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_197\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma anticonceptivos?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_197'>\n\t\t\t<li class='gchoice gchoice_1_197_0'>\n\t\t\t\t<input name='input_197' type='radio' value='S\u00ed'  id='choice_1_197_0'    \/>\n\t\t\t\t<label for='choice_1_197_0' id='label_1_197_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_197_1'>\n\t\t\t\t<input name='input_197' type='radio' value='No'  id='choice_1_197_1'    \/>\n\t\t\t\t<label for='choice_1_197_1' id='label_1_197_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_198\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_198'><span class='gform-field-label__text'>Qu\u00e9 tipo de anticonceptivo<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_198' id='input_1_198' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='P\u00edldora anticonceptiva' >P\u00edldora anticonceptiva<\/option><option value='Parche anticonceptivo' >Parche anticonceptivo<\/option><option value='Anillo vaginal' >Anillo vaginal<\/option><option value='Inyecci\u00f3n anticonceptiva' >Inyecci\u00f3n anticonceptiva<\/option><option value='Implante subd\u00e9rmico' >Implante subd\u00e9rmico<\/option><option value='Dispositivo intrauterino hormonal' >Dispositivo intrauterino hormonal<\/option><option value='Dispositivo intrauterino de cobre' >Dispositivo intrauterino de cobre<\/option><option value='Preservativo masculino' >Preservativo masculino<\/option><option value='Preservativo femenino' >Preservativo femenino<\/option><option value='Diafragma' >Diafragma<\/option><option value='Capuch\u00f3n cervical' >Capuch\u00f3n cervical<\/option><option value='Esponja anticonceptiva' >Esponja anticonceptiva<\/option><option value='Espermicida' >Espermicida<\/option><\/select><\/div><\/li><li id=\"field_1_199\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1 en terapia de reemplazo hormonal?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_199'>\n\t\t\t<li class='gchoice gchoice_1_199_0'>\n\t\t\t\t<input name='input_199' type='radio' value='S\u00ed'  id='choice_1_199_0'    \/>\n\t\t\t\t<label for='choice_1_199_0' id='label_1_199_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_199_1'>\n\t\t\t\t<input name='input_199' type='radio' value='No'  id='choice_1_199_1'    \/>\n\t\t\t\t<label for='choice_1_199_1' id='label_1_199_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_200\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_200'><span class='gform-field-label__text'>Especifique la terapia de reemplazo hormonal<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_1_200' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_201\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTiene alg\u00fan dispositivo implantado?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_201'>(Marcapasos, DIU, pr\u00f3tesis, etc.)\n<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_201'>\n\t\t\t<li class='gchoice gchoice_1_201_0'>\n\t\t\t\t<input name='input_201' type='radio' value='S\u00ed'  id='choice_1_201_0'    \/>\n\t\t\t\t<label for='choice_1_201_0' id='label_1_201_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_201_1'>\n\t\t\t\t<input name='input_201' type='radio' value='No'  id='choice_1_201_1'    \/>\n\t\t\t\t<label for='choice_1_201_1' id='label_1_201_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_202\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_202'><span class='gform-field-label__text'>Especifique el dispositivo implantado<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_1_202' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_203\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1 usando actualmente Ozempic, Mounjaro u otro m\u00e9todo para la p\u00e9rdida de peso?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_203'>\n\t\t\t<li class='gchoice gchoice_1_203_0'>\n\t\t\t\t<input name='input_203' type='radio' value='S\u00ed'  id='choice_1_203_0'    \/>\n\t\t\t\t<label for='choice_1_203_0' id='label_1_203_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_203_1'>\n\t\t\t\t<input name='input_203' type='radio' value='No'  id='choice_1_203_1'    \/>\n\t\t\t\t<label for='choice_1_203_1' id='label_1_203_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_204'><span class='gform-field-label__text'>Especifique el medicamento para acn\u00e9 que utiliza<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_1_204' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1 tomando Roacutan u otro tratamiento similar para el acn\u00e9?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_205'>\n\t\t\t<li class='gchoice gchoice_1_205_0'>\n\t\t\t\t<input name='input_205' type='radio' value='S\u00ed'  id='choice_1_205_0'    \/>\n\t\t\t\t<label for='choice_1_205_0' id='label_1_205_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_205_1'>\n\t\t\t\t<input name='input_205' type='radio' value='No'  id='choice_1_205_1'    \/>\n\t\t\t\t<label for='choice_1_205_1' id='label_1_205_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_125\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_125'><span class='gform-field-label__text'>\u00bfFuma o Fumaba?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_125'>Cigarrillos, cigarros, cigarrillo electr\u00f3nico \/ vape, huka, etc.<\/div><div class='ginput_container ginput_container_select'><select name='input_125' id='input_1_125' class='small gfield_select'  aria-describedby=\"gfield_description_1_125\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Si' >Si<\/option><option value='No' >No<\/option><option value='Fumaba' >Fumaba<\/option><\/select><\/div><\/li><li id=\"field_1_147\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_147'><span class='gform-field-label__text'>\u00bfQu\u00e9 fuma o fumaba y con qu\u00e9 frecuencia?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_1_147' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEres al\u00e9rgico alg\u00fan medicamento?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_36'>\n\t\t\t<li class='gchoice gchoice_1_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='S\u00ed'  id='choice_1_36_0'    \/>\n\t\t\t\t<label for='choice_1_36_0' id='label_1_36_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_1_36_1'    \/>\n\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_54'><span class='gform-field-label__text'>\u00bfA cu\u00e1l(es) medicamentos eres al\u00e9rgico?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_1_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_159'>\n\t\t\t<li class='gchoice gchoice_1_159_0'>\n\t\t\t\t<input name='input_159' type='radio' value='S\u00ed'  id='choice_1_159_0'    \/>\n\t\t\t\t<label for='choice_1_159_0' id='label_1_159_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_159_1'>\n\t\t\t\t<input name='input_159' type='radio' value='No'  id='choice_1_159_1'    \/>\n\t\t\t\t<label for='choice_1_159_1' id='label_1_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_82'><span class='gform-field-label__text'>\u00bfCon qu\u00e9 frecuencia toma alcohol?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_1_82' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_160\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfConsumes drogas?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_160'>\n\t\t\t<li class='gchoice gchoice_1_160_0'>\n\t\t\t\t<input name='input_160' type='radio' value='S\u00ed'  id='choice_1_160_0'    \/>\n\t\t\t\t<label for='choice_1_160_0' id='label_1_160_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_160_1'>\n\t\t\t\t<input name='input_160' type='radio' value='No'  id='choice_1_160_1'    \/>\n\t\t\t\t<label for='choice_1_160_1' id='label_1_160_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_99'><span class='gform-field-label__text'>\u00bfQu\u00e9 droga consume, qu\u00e9 cantidad y con qu\u00e9 frecuencia?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHace ejercicios regularmente?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_161'>\n\t\t\t<li class='gchoice gchoice_1_161_0'>\n\t\t\t\t<input name='input_161' type='radio' value='S\u00ed'  id='choice_1_161_0'    \/>\n\t\t\t\t<label for='choice_1_161_0' id='label_1_161_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_161_1'>\n\t\t\t\t<input name='input_161' type='radio' value='No'  id='choice_1_161_1'    \/>\n\t\t\t\t<label for='choice_1_161_1' id='label_1_161_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_102\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_102'><span class='gform-field-label__text'>D\u00edas y horas que hace ejercicios<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_1_102' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_162\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfLleva usted una dieta balanceada?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_162'>\n\t\t\t<li class='gchoice gchoice_1_162_0'>\n\t\t\t\t<input name='input_162' type='radio' value='S\u00ed'  id='choice_1_162_0'    \/>\n\t\t\t\t<label for='choice_1_162_0' id='label_1_162_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_162_1'>\n\t\t\t\t<input name='input_162' type='radio' value='No'  id='choice_1_162_1'    \/>\n\t\t\t\t<label for='choice_1_162_1' id='label_1_162_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfSe ha aplicado alguna vez rellenos faciales o corporales?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_153'>\n\t\t\t<li class='gchoice gchoice_1_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='S\u00ed'  id='choice_1_153_0'    \/>\n\t\t\t\t<label for='choice_1_153_0' id='label_1_153_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_1_153_1'    \/>\n\t\t\t\t<label for='choice_1_153_1' id='label_1_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_150\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Selecciones los rellenos faciales \/ corporales que se ha aplicado<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_150'><li class='gchoice gchoice_1_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='\u00c1cido hialur\u00f3nico (facial)'  id='choice_1_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_1' id='label_1_150_1' class='gform-field-label gform-field-label--type-inline'>\u00c1cido hialur\u00f3nico (facial)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='Hidroxiapatita c\u00e1lcica (facial)'  id='choice_1_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_2' id='label_1_150_2' class='gform-field-label gform-field-label--type-inline'>Hidroxiapatita c\u00e1lcica (facial)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_150_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.3' type='checkbox'  value='\u00c1cido polil\u00e1ctico (facial)'  id='choice_1_150_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_3' id='label_1_150_3' class='gform-field-label gform-field-label--type-inline'>\u00c1cido polil\u00e1ctico (facial)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_150_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.4' type='checkbox'  value='Biopol\u00edmeros (facial)'  id='choice_1_150_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_4' id='label_1_150_4' class='gform-field-label gform-field-label--type-inline'>Biopol\u00edmeros (facial)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_150_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.5' type='checkbox'  value='Grasa aut\u00f3loga (facial)'  id='choice_1_150_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_5' id='label_1_150_5' class='gform-field-label gform-field-label--type-inline'>Grasa aut\u00f3loga (facial)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_150_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.6' type='checkbox'  value='Grasa aut\u00f3loga (corporal)'  id='choice_1_150_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_150_6' id='label_1_150_6' class='gform-field-label gform-field-label--type-inline'>Grasa aut\u00f3loga (corporal)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa recibido alg\u00fan otro tratamientos est\u00e9ticos no quir\u00fargicos en el \u00faltimo a\u00f1o?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_193'>(Botox, rellenos, hilos tensores, bioestimuladores, etc.)\n<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_193'>\n\t\t\t<li class='gchoice gchoice_1_193_0'>\n\t\t\t\t<input name='input_193' type='radio' value='Si'  id='choice_1_193_0'    \/>\n\t\t\t\t<label for='choice_1_193_0' id='label_1_193_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_193_1'>\n\t\t\t\t<input name='input_193' type='radio' value='No'  id='choice_1_193_1'    \/>\n\t\t\t\t<label for='choice_1_193_1' id='label_1_193_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_194\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_194'><span class='gform-field-label__text'>Favor describa los tratamientos est\u00e9ticos que ha recibido<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_194' id='input_1_194' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_178' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_1_178' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Pr\u00f3ximo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-178' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_86\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Cirug\u00edas Anteriores<\/h2><\/li><li id=\"field_1_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfSe ha realizado alguna cirug\u00eda general o est\u00e9tica?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_146'>Ces\u00e1rea, bari\u00e1trica, apendectom\u00eda, extracci\u00f3n de ves\u00edcula, reducci\u00f3n de mamas, liposucci\u00f3n, etc.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_146'>\n\t\t\t<li class='gchoice gchoice_1_146_0'>\n\t\t\t\t<input name='input_146' type='radio' value='S\u00ed'  id='choice_1_146_0'    \/>\n\t\t\t\t<label for='choice_1_146_0' id='label_1_146_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_146_1'>\n\t\t\t\t<input name='input_146' type='radio' value='No'  id='choice_1_146_1'    \/>\n\t\t\t\t<label for='choice_1_146_1' id='label_1_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Seleccione el tipo de cirug\u00eda que se ha realizado enteriormente<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_74'><li class='gchoice gchoice_1_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Cirug\u00eda General (bari\u00e1trica, apendectom\u00eda, extracci\u00f3n de ves\u00edcula,etc.)'  id='choice_1_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_74_1' id='label_1_74_1' class='gform-field-label gform-field-label--type-inline'>Cirug\u00eda General (bari\u00e1trica, apendectom\u00eda, extracci\u00f3n de ves\u00edcula,etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Cirug\u00edas Est\u00e9ticas anteriores (reducci\u00f3n de mamas, liposucci\u00f3n, etc.)'  id='choice_1_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_74_2' id='label_1_74_2' class='gform-field-label gform-field-label--type-inline'>Cirug\u00edas Est\u00e9ticas anteriores (reducci\u00f3n de mamas, liposucci\u00f3n, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_179\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_179'><span class='gform-field-label__text'>Cirug\u00eda Est\u00e9tica anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_179'>Favor especifique el tipo de cirug\u00eda(s), la fecha estimada en que se la realiz\u00f3 y si tuvo alguna complicaci\u00f3n en dicha cirug\u00eda.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_179' id='input_1_179' class='textarea small'  aria-describedby=\"gfield_description_1_179\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_180\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_180'><span class='gform-field-label__text'>Cirug\u00eda General anterior<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_180'>Favor especifique el tipo de cirug\u00eda(s), la fecha estimada en que se la realiz\u00f3 y si tuvo alguna complicaci\u00f3n en dicha cirug\u00eda.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_180' id='input_1_180' class='textarea small'  aria-describedby=\"gfield_description_1_180\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_181\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_181'><span class='gform-field-label__text'>Hospitalizaciones pasadas<\/span><\/label><div class='gfield_description' id='gfield_description_1_181'>Favor especifique si ha sido hospitalizado por alg\u00fan otro motivo.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_181' id='input_1_181' class='textarea small'  aria-describedby=\"gfield_description_1_181\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa tenido complicaciones previas con cirug\u00edas est\u00e9ticas o tratamientos?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_195'>\n\t\t\t<li class='gchoice gchoice_1_195_0'>\n\t\t\t\t<input name='input_195' type='radio' value='Si'  id='choice_1_195_0'    \/>\n\t\t\t\t<label for='choice_1_195_0' id='label_1_195_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_195_1'>\n\t\t\t\t<input name='input_195' type='radio' value='No'  id='choice_1_195_1'    \/>\n\t\t\t\t<label for='choice_1_195_1' id='label_1_195_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_196\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_196'><span class='gform-field-label__text'>Favor describa las complicaciones que ha tenido<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_196' id='input_1_196' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_206\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa recibido transfusiones sangu\u00edneas?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_206'>\n\t\t\t<li class='gchoice gchoice_1_206_0'>\n\t\t\t\t<input name='input_206' type='radio' value='Si'  id='choice_1_206_0'    \/>\n\t\t\t\t<label for='choice_1_206_0' id='label_1_206_0' class='gform-field-label gform-field-label--type-inline'>Si<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_206_1'>\n\t\t\t\t<input name='input_206' type='radio' value='No'  id='choice_1_206_1'    \/>\n\t\t\t\t<label for='choice_1_206_1' id='label_1_206_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_90\" class=\"gfield gfield--type-section gfield--input-type-section gsection pagebreak field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Contacto de Emergencia<\/h2><\/li><li id=\"field_1_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_92'><span class='gform-field-label__text'>Nombre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_1_92' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_88\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_88'><span class='gform-field-label__text'>Relaci\u00f3n<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_1_88' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_89\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-international gfield--width-third gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_89'><span class='gform-field-label__text'>Tel\u00e9fono<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_89' id='input_1_89' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <button type='button' id='gform_previous_button_1_177' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='button' id='gform_next_button_1_177' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Pr\u00f3ximo<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-177' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_111\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 style=color:#151b54; padding-top:50px;\">Env\u00edanos tus fotos (de frente, laterales y de espalda)<\/h3>\n<ul><li>Evaluaciones faciales (por favor incluya \u00e1ngulo de frente y ambos perfiles, del cuello para arriba)<\/li>        <li>Evaluaciones corporales (por favor incluya \u00e1ngulos de frente, de lado y de espalda, sin levantar los brazos y sin exponer su rostro)<\/li>\n<li>SI su procedimiento deseado es de mamas, tome las fotos sin sost\u00e9n \/ brasier.<\/li><\/ul><br \/><br \/>\n<img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/fernandezgoico.com\/wp-content\/uploads\/2024\/03\/foto-ilustration2.png\" height=\"300\" width=\"385\" \/><\/li><li id=\"field_1_112\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_112'><span class='gform-field-label__text'>Foto Frontal<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_112' id='input_1_112' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_112\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_112'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_112'><\/div> <\/div><\/li><li id=\"field_1_113\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_113'><span class='gform-field-label__text'>Foto Lateral<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_113' id='input_1_113' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_113\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_113'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_113'><\/div> <\/div><\/li><li id=\"field_1_114\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_114'><span class='gform-field-label__text'>Foto de Espalda<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_114' id='input_1_114' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_114\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_114'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_114'><\/div> <\/div><\/li><li id=\"field_1_115\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_left_third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_115'><span class='gform-field-label__text'>Foto Adicional 1<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_115' id='input_1_115' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_115\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_115'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_115'><\/div> <\/div><\/li><li id=\"field_1_116\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_middle_third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_116'><span class='gform-field-label__text'>Foto Adicional 2<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_116' id='input_1_116' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_116\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_116'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_116'><\/div> <\/div><\/li><li id=\"field_1_117\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gf_right_third field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_117'><span class='gform-field-label__text'>Foto Adicional 3<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_117' id='input_1_117' type='file' class='medium' aria-describedby=\"gfield_upload_rules_1_117\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_1_117'>Max. file size: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_1_117'><\/div> <\/div><\/li><li id=\"field_1_120\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_1_189\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><label class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfAlg\u00fan familiar, amigo o conocido se ha operado o evaluado con el Dr. Fern\u00e1ndez Goico?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_189'>\n\t\t\t<li class='gchoice gchoice_1_189_0'>\n\t\t\t\t<input name='input_189' type='radio' value='S\u00ed'  id='choice_1_189_0'    \/>\n\t\t\t\t<label for='choice_1_189_0' id='label_1_189_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_189_1'>\n\t\t\t\t<input name='input_189' type='radio' value='No'  id='choice_1_189_1'    \/>\n\t\t\t\t<label for='choice_1_189_1' id='label_1_189_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_190\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_190'><span class='gform-field-label__text'>Especifique el nombre del familiar o amigo<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_1_190' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_191\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_191'><span class='gform-field-label__text'>\u00bfC\u00f3mo conoci\u00f3 la consulta \/ al doctor?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_191' id='input_1_191' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Referido por otro paciente de FG' >Referido por otro paciente de FG<\/option><option value='Instagram' >Instagram<\/option><option value='Referido por otro m\u00e9dico' >Referido por otro m\u00e9dico<\/option><option value='Publicidad' >Publicidad<\/option><option value='B\u00fasqueda en Google' >B\u00fasqueda en Google<\/option><option value='Otro' >Otro<\/option><\/select><\/div><\/li><li id=\"field_1_192\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_192'><span class='gform-field-label__text'>Favor especifique<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_1_192' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'><span class='gform-field-label__text'>Comentarios<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_1_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_139\" class=\"gfield gfield--type-section gfield--input-type-section gsection pdf_no_display field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Consentimiento<\/h2><div class='gsection_description' id='gfield_description_1_139'><h4 style=\"margin-top:30px;\">Lea detenidamente los t\u00e9rminos<\/h4>\n<p style=\"font-size:12px; line-height:22px;\">Yo, {Nombre (Nombre):16.3} {Nombre (Apellidos):16.6}, portador (a) de la c\u00e9dula de identidad y electoral y\/o pasaporte No. {{No. de c\u00e9dula:137}{No. de pasaporte:138}, de nacionalidad {Nacionalidad:135}, en el d\u00eda {date_dmy}. DECLARO BAJO LA FE JURAMENTO, soy la (el) \u00fanica (\u00fanico)\u00a0 responsable ante todo da\u00f1o que me acaree cualquier omisi\u00f3n a la mala informaci\u00f3n\u00a0 que haya vertido en este documento despu\u00e9s de haber le\u00eddo detenidamente las preguntas realizadas por el Doctor Fern\u00e1ndez Goico, y comprendo que ocultar cualquier tipo de informaci\u00f3n m\u00e9dica a este o su personal m\u00e9dico, podr\u00eda poner en riesgo mi vida y salud, as\u00ed como la obligaci\u00f3n que tengo de notificar cualquier cambio o alternaci\u00f3n sobre las informaciones aqu\u00ed provistas.\n<br \/><br \/>\nFirma del paciente<br \/><br \/><br \/>\n\n\n ______________________________<br \/>\n {Nombre (Nombre):16.3} {Nombre (Apellidos):16.6}<\/p><\/div><\/li><li id=\"field_1_140\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden gfield--choice-align-vertical\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Cotizacion 1<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_140'><li class='gchoice gchoice_1_140_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_140.1' type='checkbox'  value='Pendiente' checked='checked' id='choice_1_140_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_140_1' id='label_1_140_1' class='gform-field-label gform-field-label--type-inline'>Pendiente<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><button type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' >Anterior<\/button> <button type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Enviar<\/button> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=b4dfef759f96fa48b6df20ce89e8683d' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='MbE8ZgqYrnISmBa44ZP0hXgL\/gNuRyv7osXNeLNR5wGLSFKXB3c2p4w8tTrWMHxaLl52eo8QCGHqen21I69F00J\/WQPFiUG+bKK3ji\/O9XhsuQM=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='["{\"154\":[\"bf03c41c8cc0850905ff4e4e628ff96a\",\"0f646d8afccb992e323aaa69e9ae8d03\"],\"208\":[\"da75da2171526f1c7d86cc41b3e7b344\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"163\":[\"62308bdb911ab2fc2f8b8256c35a69e9\",\"15f4fe8f90063ae69d73be9f18954fe3\",\"cf72e755c86422a0ba1a44399f6cac53\"],\"168\":[\"ee0ce9fe5618a5a05b35687d3f661348\",\"5c3bb850fd641cb0fbb4135cfb8a877c\",\"d37f4ca9884a0aadf556c2b1e88ae6a5\",\"16eba8506321929ad6a30383bf6e2641\",\"f438bb053cdfd3f0a06628d04ff41943\",\"53aac8f27be81fa6baa3d23ab4e17371\",\"6f00970b9d565c738ffd12258c42196f\",\"5fd78f0f8e4d824a008afc31d93c200d\",\"7d2cbb8fe548dca72fcef0e78adb4298\",\"09fb0988e2af6443bb1545b788e9af88\",\"41c7308df26ed49233929d6050e501f1\",\"660f2ba109b9b2a00d343124e1f67916\",\"4e99f2e233be1bd8dc84ed37bcc5ca7a\",\"321d47fad97871293cd1446f824810d9\",\"36801b56f1f7f40c423d2a7e3f2ecd3f\",\"b03159dcbe6eab520e4fb272c4aaab8f\",\"f50f25837a5554d9ec7fa59c983a0d10\",\"654bc0177a839b1bca35ebb8f6c2099a\",\"1ff4ebae06b00f982f56813c55f4c9f2\",\"cc23ce1c14f4234af05e9035bb8bd086\",\"0f63c9c60c37292eadd0c1a4533da496\",\"980da9bf7d918cd47daf45cc0255f9bd\",\"a72bf7a1e17f7d6857396db02417cf9d\",\"bee4762f658e13c3afdcd7341f87b551\",\"ac78c5f1e542068c2de5db9de9711e28\",\"35175a8969166918671d6541421d8079\",\"201aeeda27cab5e0f04cce96e25a9255\",\"fb7c67d37977dc34474924d1571f18e0\",\"45939e8ca69d3f93f2a1df948727c34c\",\"129a4139fc8fb6da0b9b26b59656d24b\",\"e9c432fc8daaa765cd0b3d2d69fdcbad\",\"26ca7bd73ec983ad8d836e556ef65d80\",\"00ba4530548ea7c035394a528b9a5221\",\"f7c9be8480f5a4770bc3f3f82a182e6d\",\"31a91200621ce84acb7e5f289cd314f4\",\"d26b488ddfe31045bebfcdaa1835deeb\",\"dfcc0cd747283dd5d060a4925ea6e914\",\"7ec87b317a8e19d5738b18c9da604a01\"],\"165.1\":\"14c272438ac132ea9b45ad2dc56ab193\",\"165.2\":\"a64e31c6333e9e1715d16ee68325058b\",\"165.3\":\"22a6805b29071cda585299408dbfc221\",\"165.4\":\"8a6f850efe0715b29c68e1bdfa9026ed\",\"165.5\":\"d891436f546d909d644a4ede5e5005f0\",\"165.6\":\"c878430ad0d37b0eef940ef82b625141\",\"165.7\":\"53a0a52190aed8589ac4edfc54d825d7\",\"165.8\":\"2b7233481a65318e376bcb93d66cde8e\",\"165.9\":\"44e611793ebe97d4e57e7c47a77479b9\",\"155\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"156\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"157\":[\"1d8ca7d8562f510dc1af0623e73e53b0\",\"5ac29026ffcf6e89ec014e1b894eeb45\"],\"186\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"187\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"183\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"184\":[\"56a71b850aa419fb192621490edb1708\",\"8e1be58def43db2ca2983ca1d0647052\",\"0d08cbe7db25bb3b46f4a9cf7cf7defb\",\"f2303106e41b930153a4499ec6be2144\",\"8e6c16edd77d6a43715efddd40a633d4\",\"e75c530752f69e2573be945a9600d802\",\"e8f27efa5fa5e66f924eaa43eee78e5b\",\"ab1766c94f8f4e0e7f81a44a5d8c32c8\",\"56b6b7b379e42b217a2159bdb961d49b\",\"9f9c5c52596227cd9fa363905cc33578\",\"83dad78dd4a9e1f7d9935c53ab631103\",\"c40dee7125efaceacb84e32f39abd429\",\"85597b3618ec713569354528c4585550\",\"80e0c468bef418b95b73777bec75efae\",\"bfbf60bdd94bc78eb957d04bacbf7e29\",\"82822e3ac4341a604805910a66dcc83a\",\"95ef09b2d45717a455d59189874aa246\",\"e24cc28780f7e132b2707ba13d7888e9\",\"5c449420de4b906875e86d2b7ecaaca3\",\"b3555a223129f548d975889a19bc9fed\",\"eeeb1cce19f8ccb8c17c44e6376ff641\",\"3a7e0baafab47dc1d78e988b2cdb520d\",\"0ae51c7a1c8cd3b6b5a4411362a737a0\",\"30e03b403b590e0d23ebc02b8bfb012a\",\"10e12dbd401d579cd502dd6f97a612a1\",\"c562336db09879baf629c0e1e5d84657\",\"036164be7b3649d4a7f3aa97f2b0e7f2\",\"c9e7d56b2cd8ca06044ad1807adc5f4f\",\"75e47afe383868ab72d11307ca89e649\",\"72e56f1d6964eedc025f3565e368d4e5\",\"9ff9ba3089e7f9b5f3caa316ab9dc1e3\",\"b2ec29a1b02482765a1f11818c48bc78\",\"09ddfb2ae7a49231f13727a1bfe742be\",\"c0d63f1796d40a8fe7c988c4dc3ec3b8\",\"16cf0b54bce64900982f4df992942252\",\"787c1a613bfa00484d6075d8d50e5f40\",\"bb75eec337338d39c13325349927ca2a\",\"57e83464f5f2660a771c0bd1c77467eb\",\"20182baebbae0a6ba390f314128a06ab\",\"11097aa86bae18c8dcbc3e028e14fd09\",\"b632cbf6706faa40e4c65817181f6e7a\",\"a957dc14f42e1ee8631d3bc15f60af0d\",\"868397744e8f073e0c2777a50ce322fd\"],\"158\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"197\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"199\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"201\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"203\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"205\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"159\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"160\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"161\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"162\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"153\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"150.1\":\"30f6a11e0cc0bcf1392b7a0030b4b7be\",\"150.2\":\"42b3c812cc6bbe3b04a1f4f71b8e1a65\",\"150.3\":\"30c5c0159fdd34c9d8a76da939c4cb64\",\"150.4\":\"4882401e677c1534b7b0303776725d75\",\"150.5\":\"650f71f4f0e2413bcb67c0bf07dc6148\",\"150.6\":\"97b113ac276ff237fd8f43275b784e6e\",\"193\":[\"da75da2171526f1c7d86cc41b3e7b344\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"146\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"195\":[\"da75da2171526f1c7d86cc41b3e7b344\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"206\":[\"da75da2171526f1c7d86cc41b3e7b344\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"189\":[\"bd6924e10426caf824c1f3411fab876b\",\"3c9ea7fe6efa171198ecc0c51ab0e073\"],\"191\":[\"12e1668936b305095ab85d3b968f6897\",\"c663b350782a2494a720e7afc811ffbc\",\"4a41002f06123c2c2b2e37aa5ff655d4\",\"531f42824e729f518d8a07b8058476d4\",\"fe461750fce6f9ae8cfc0ec2d82ae868\",\"87f9bcfb21812a20d0c29a5b298775d1\"],\"gform_submission_method\":[\"a397eb0e6992befe4fff98d0c25a3e75\",\"ebf89a702a172551f02f2536939e8f90\",\"8d949bbd6375ba912f0b5bf10efce44a\"],\"gform_theme\":\"d71ab13251d92f0cc676ab2f3e4426be\",\"gform_style_settings\":\"1d84a49431cb0e3b46543977d5ee6ad2\",\"form_id\":\"ce13e3c8e973388cca4c74a67091503f\",\"url\":\"57fdd660b3f5338e79834bfd0c10c028\",\"state_timestamp\":\"3844b38001922d6eb9ae2f45c3b82e11\"}","35853e8738e171fc1fd19907f29756a7",1789422855]' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );var current_page = jQuery('#gform_source_page_number_1').val();jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 1, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<div class=\"w-separator size_medium\"><\/div><\/div><\/div><\/div><\/div><\/div><\/section>\n","protected":false},"excerpt":{"rendered":"Solicita una Evaluaci\u00f3n Step 1 of 4 25% Para verificar si es candidato\/a a la cirug\u00eda que desea, por favor complete este formulario con sus datos y adjunte fotos de las \u00e1reas a tratar. Ya sea en consulta presencial o virtual con el Dr. Fern\u00e1ndez, es importante que sea honesto\/a y preciso\/a en sus respuestas....","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"footnotes":""},"class_list":["post-22","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/pages\/22","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/comments?post=22"}],"version-history":[{"count":0,"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/pages\/22\/revisions"}],"wp:attachment":[{"href":"https:\/\/fernandezgoico.com\/en\/wp-json\/wp\/v2\/media?parent=22"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}