{"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\/en\/\" 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\">Request an Evaluation<\/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 type=\"text\/javascript\">\n\/* <![CDATA[ *\/\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\/* ]]> *\/\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 data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/22#gf_1\">\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;\">To verify if you are a candidate for the desired surgery, please complete this form with your information and attach photos of the areas to be treated. Whether it is in-person or virtual consultation with Dr. Fern\u00e1ndez, it is important to be honest and precise in your answers. Your safety and the success of the procedure are our priority.<\/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\"  ><label class='gfield_label gform-field-label' >Sex<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' >Name<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='Names)'  \/>\n                                                    <label for='input_1_16_3' class='gform-field-label gform-field-label--type-sub'>Names)<\/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='Surnames)'  \/>\n                                                    <label for='input_1_16_6' class='gform-field-label gform-field-label--type-sub'>Surnames)<\/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-no-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'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_67' id='input_1_67' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd \/ mm \/ yyyy' aria-describedby=\"input_1_67_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_67_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_67' class='gform_hidden' value='https:\/\/fernandezgoico.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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'>Age<\/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'>Nationality<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'>Profession<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\"  ><label class='gfield_label gform-field-label' >Type of document of identy<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'>Passport<\/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'>C\u00e9dula Number<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'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/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'>Passport Number<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'>E-mail<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 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'>Mobile \/ Whatsapp<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'>Instagram user:<\/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' >Address<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='Street, 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='State \/ Province' 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='' >Country<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cape Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d &amp; #039; Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >The Savior<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy see<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >sweater<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People &amp; #039; s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macau<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >malt<\/option><option value='Marshall Islands' >Marshall islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >Meeting<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >Turkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, US<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfViajar\u00eda desde otra ciudad o pa\u00eds para la cirug\u00eda?<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'>Yes<\/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\"  ><label class='gfield_label gform-field-label' >Choose your preferred consultation method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_163'>Note: The cost of the evaluation will be applied to the total quoted amount of the procedure.<\/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'>In-Person Evaluation<\/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'>Photo Evaluation<\/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'>Video call with the 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'>Reason for consultation<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' >Inesthetic Scar<\/option><option value='Evaluaci\u00f3n Abdomen' >Abdomen Evaluation<\/option><option value='Evaluaci\u00f3n Corporal' >Body Assessment<\/option><option value='Evaluaci\u00f3n Facial' >Facial Evaluation<\/option><option value='Evaluaci\u00f3n General' >General evaluation<\/option><option value='Evaluaci\u00f3n Gl\u00fateos' >Buttock Evaluation<\/option><option value='Evaluaci\u00f3n Regi\u00f3n \u00cdntima' >Intimate Region Assessment<\/option><option value='Evaluaci\u00f3n Senos' >Breast Evaluation<\/option><option value='Revisi\u00f3n de Cirug\u00eda Anterior' >Review of Previous Surgery<\/option><option value='Otro' >Other<\/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'>Another reason for consultation<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'>\u00bfCu\u00e1l es su principal objetivo o expectativa de la cirug\u00eda?<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'>What date would you prefer for the surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_207'>Select a preferred date, bearing in mind that this does NOT COUNT AS A SURGERY RESERVATION. <\/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'>Who recommended Dr. Fern\u00e1ndez to you or how did you find us?<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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Procedures of interest (Check all that apply)<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'>Facial Fillers<\/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'>Rhinoplasty<\/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'>Otoplasty (Ear Surgery)<\/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'>Genioplasty (Chin Surgery)<\/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'>Blepharoplasty (Eyelid Surgery)<\/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'>Double chin liposuction<\/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'>Neck Lift<\/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'>Face Lift<\/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'>Bichectomy<\/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'>Breast augmentation<\/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'>Breast lift<\/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'>Breast Reduction<\/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'>Change or removal of implants<\/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'>Vaser general liposuction<\/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'>Arms liposuction<\/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'>Thigh liposuction<\/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'>Abdominal Vaser Definition<\/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'>Gluteal Lipoinjection (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'>Abdominoplasty (with strengthening of abdominal muscles)<\/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'>Mini Abdominoplasty (without abdominal muscle repair)<\/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'>Scar correction<\/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'>Hernia repair<\/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'>Gynecomastia (Reduction of the male mammary glands)<\/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'>Arm Lifting<\/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'>Thigh lift<\/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'>Other<\/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'>Another procedure of interest<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\"  ><label class='gfield_label gform-field-label' >Please specify the reason for the replacement or removal of implants<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'>Rupture or encapsulation of the implant<\/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'>Change the size of implants or improve aesthetic appearance<\/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'>My implants are more than 10 years old and I was informed that I had to change them<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input 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' value='Next'  \/> \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\">CLINICAL DATA<\/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'>Current Weight (lbs)<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'>Height (ft.,in.)<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&#039;10<\/option><option value='59' >4&#039;11<\/option><option value='60' >5&#039;0<\/option><option value='61' >5&#039;1<\/option><option value='62' >5&#039;2<\/option><option value='63' >5&#039;3<\/option><option value='64' >5&#039;4<\/option><option value='65' >5&#039;5<\/option><option value='66' >5&#039;6<\/option><option value='67' >5&#039;7<\/option><option value='68' >5&#039;8<\/option><option value='69' >5&#039;9<\/option><option value='70' >5\u201910<\/option><option value='71' >5&#039;11<\/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'>BMI<\/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\">Dr. Fern\u00e1ndez does not perform surgical procedures on patients with a BMI (Body Mass Index) equal to or greater than 30.<br \/>In this case, it is recommended to reach a healthier weight and request an appointment at that time for a more objective evaluation.<\/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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you suffer or have you suffered from any of these diseases or health conditions? Check all that apply.<\/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'>Heart disease<\/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'>Carrier of 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'>Thrombophlebitis<\/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'>Venous thrombosis<\/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'>Varicose veins<\/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'>Psychiatric illness<\/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'>Constipation (constipation)<\/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'>Blood pressure<\/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'>Bleeding<\/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'>Thyroid<\/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'>Asthma<\/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'>History of 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 (AIDS)<\/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'>Gynecological condition (polyps, uterine fibroids, polycystic ovary syndrome, ovarian cyst, breast cyst)<\/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'>Other<\/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'>Please specify your health problem<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'>Favor especifique su enfermedad psiqui\u00e1trica<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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Has anyone in your immediate family (parents, siblings, children) been diagnosed with or have a history of any of the following health conditions? Please check all that apply:<\/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'>Type 2 Diabetes<\/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'>High blood pressure<\/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'>Others<\/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'>Otros antecedentes familaires<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\"  ><label class='gfield_label gform-field-label' >Do you take any medications or supplements regularly (for blood pressure, anti-depressants, protein, weight loss supplements, vitamins)?<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'>Yes<\/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'>Specify the medications \/ supplements you take<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\"  ><label class='gfield_label gform-field-label' >\u00bfHa sufrido Tromboembolismo Pulmonar?<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'>Yes<\/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'>\u00bfCu\u00e1ndo sufriste Tromboembolismo Pulmonar?<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'>Blood type<\/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' >TO<\/option><option value='A+' >A +<\/option><option value='A-' >TO-<\/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' >OR<\/option><option value='O+' >O +<\/option><option value='O-' >OR-<\/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\"  ><label class='gfield_label gform-field-label' >Do you have or have you had child(ren)?<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'>Yes<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfC\u00f3mo fue su \u00faltimo parto?<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'>Natural birth<\/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'>Caesarean section<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfSu \u00faltimo parto fue hace 1 a\u00f1o o menos?<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'>Yes<\/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-no-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'>Date of your last delivery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_1_73' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd \/ mm \/ yyyy' aria-describedby=\"input_1_73_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_73_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_73' class='gform_hidden' value='https:\/\/fernandezgoico.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/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\"  ><label class='gfield_label gform-field-label' >\u00bfHa amamantado a su hij(a) en los \u00faltimos 6 meses?<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'>Yes<\/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'>Fecha en que suspendi\u00f3 lactancia<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\"  ><label class='gfield_label gform-field-label' >\u00bfEst\u00e1s embarazada actualmente?<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'>Yes<\/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'>Semanas de gestaci\u00f3n<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\"  ><label class='gfield_label gform-field-label' >Do you plan to have (more) children?<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'>Yes<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfToma anticonceptivos?<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'>Yes<\/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'>Qu\u00e9 tipo de anticonceptivo<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\"  ><label class='gfield_label gform-field-label' >\u00bfEst\u00e1 en terapia de reemplazo hormonal?<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'>Yes<\/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'>Especifique la terapia de reemplazo hormonal<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\"  ><label class='gfield_label gform-field-label' >\u00bfTiene alg\u00fan dispositivo implantado?<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'>Yes<\/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'>Especifique el dispositivo implantado<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\"  ><label class='gfield_label gform-field-label' >\u00bfEst\u00e1 usando actualmente Ozempic, Mounjaro u otro m\u00e9todo para la p\u00e9rdida de peso?<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'>Yes<\/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'>Especifique el medicamento para acn\u00e9 que utiliza<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\"  ><label class='gfield_label gform-field-label' >\u00bfEst\u00e1 tomando Roacutan u otro tratamiento similar para el acn\u00e9?<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'>Yes<\/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'>Do you smoke or have you smoked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_125'>Cigarettes, cigars, electronic cigarettes \/ vape, hookah, 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' >Yes<\/option><option value='No' >No<\/option><option value='Fumaba' >Smoked<\/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'>\u00bfQu\u00e9 fuma o fumaba y con qu\u00e9 frecuencia?<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\"  ><label class='gfield_label gform-field-label' >Are you allergic to any medications?<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'>Yes<\/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'>Which medications are you allergic to?<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\"  ><label class='gfield_label gform-field-label' >Do you drink alcohol?<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'>Yes<\/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'>How often do you drink alcohol?<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\"  ><label class='gfield_label gform-field-label' >Do you use drugs?<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'>Yes<\/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'>What drug do you use, how much and how often?<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\"  ><label class='gfield_label gform-field-label' >Do you exercise regularly?<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'>Yes<\/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'>Days and hours you exercise<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\"  ><label class='gfield_label gform-field-label' >Do you eat a balanced diet?<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'>Yes<\/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\"  ><label class='gfield_label gform-field-label' >Have you ever had facial or body fillers applied?<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'>Yes<\/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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Select the facial \/ body fillers you have had applied<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'>Hyaluronic acid (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'>Calcium hydroxyapatite (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'>Polylactic acid (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'>Biopolymers (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'>Autologous fat (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'>Autologous fat (body)<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfHa recibido alg\u00fan otro tratamientos est\u00e9ticos no quir\u00fargicos en el \u00faltimo a\u00f1o?<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'>Yes<\/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'>Favor describa los tratamientos est\u00e9ticos que ha recibido<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                        <input 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' value='Anterior'  \/> <input 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' value='Next'  \/> \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\">Previous Surgeries<\/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\"  ><label class='gfield_label gform-field-label' >Have you had any general or cosmetic surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_146'>C-section, bariatric surgery, appendectomy, gallbladder removal, breast reduction, liposuction, 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'>Yes<\/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\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Seleccione el tipo de cirug\u00eda que se ha realizado enteriormente<\/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'>General Surgery (bariatric, appendectomy, gallbladder removal, 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'>Previous cosmetic surgeries (breast reduction, liposuction, 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'>Previous cosmetic surgery<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'>Previous General Surgery<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'>Past Hospitalizations<\/label><div class='gfield_description' id='gfield_description_1_181'>Please specify if you have been hospitalized for any other reason.<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfHa tenido complicaciones previas con cirug\u00edas est\u00e9ticas o tratamientos?<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'>Yes<\/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'>Favor describa las complicaciones que ha tenido<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\"  ><label class='gfield_label gform-field-label' >\u00bfHa recibido transfusiones sangu\u00edneas?<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'>Yes<\/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\">Emergency contact<\/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'>Name<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'>Relationship<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--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'>Telephone<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                        <input 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' value='Anterior'  \/> <input 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' value='Next'  \/> \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;\">Send us your photos (front, side and back)<\/h3>\n<ul><li>Facial evaluations (please include forehead angle and both profiles, from the neck up)<\/li>        <li>Body Assessments (please include front, side and back angles, without raising your arms and without exposing your face)<\/li>\n<li>If your desired procedure is for the breasts, take the photos without a bra.<\/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'>Frontal Photo<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'>Lateral Photo<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'>Backside Photo<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'>Additional Photo 1<\/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'>Additional Photo 2<\/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'>Additional Photo 3<\/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\"  ><label class='gfield_label gform-field-label' >\u00bfAlg\u00fan familiar, amigo o conocido se ha operado o evaluado con el Dr. Fern\u00e1ndez Goico?<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'>Yes<\/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'>Especifique el nombre del familiar o amigo<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'>\u00bfC\u00f3mo conoci\u00f3 la consulta \/ al doctor?<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' >Other<\/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'>Favor especifique<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'>Comments<\/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\">Consent<\/h2><div class='gsection_description' id='gfield_description_1_139'><h4 style=\"margin-top:30px;\">Read the terms carefully<\/h4>\n<p style=\"font-size:12px; line-height:22px;\">I, {Name (Name): 16.3} {Name (Surname): 16.6}, bearer of the identity and electoral card and \/ or passport No. {{No. ID: 137} {No. of passport: 138}, of nationality {Nationality: 135}, on the day {date_dmy}. I DECLARE UNDER FAITH OATH, I am the sole (sole) liable for any damage caused to me by any omission to the bad information that has been spilled in this document after having carefully read the questions asked by Doctor Fern\u00e1ndez Goico, and I understand that hiding any type of medical information from him or his medical staff could put my life and health at risk, as well as the obligation that I have to notify any change or alteration of the information provided here.\n<br \/><br \/>\nPatient&#039;s signature<br \/><br \/><br \/>\n\n\n ______________________________<br \/>\n {Name (Name): 16.3} {Name (Surname): 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\"  ><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' >Quote 1<\/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'>Earring<\/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'><input 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' value='Anterior'  \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send'  \/> <input type='hidden' name='gform_ajax' value='form_id=1&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=8e73778eccbf764c5f8d906a0ff6f381' \/>\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' 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