{"id":794,"date":"2025-04-15T15:47:49","date_gmt":"2025-04-15T15:47:49","guid":{"rendered":"https:\/\/whitecoatmedspa.com\/?page_id=794"},"modified":"2025-04-16T13:00:31","modified_gmt":"2025-04-16T13:00:31","slug":"autoevaluacion-previa","status":"publish","type":"page","link":"https:\/\/whitecoatmedspa.com\/en\/autoevaluacion-previa\/","title":{"rendered":"AUTOEVALUACI\u00d3N PREVIA"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"794\" class=\"elementor elementor-794\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-d6b1e48 elementor-section-content-middle elementor-section-stretched elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"d6b1e48\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-25f486f\" data-id=\"25f486f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0b8c9f7 elementor-widget elementor-widget-form\" data-id=\"0b8c9f7\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Siguiente&quot;,&quot;step_previous_label&quot;:&quot;Anterior&quot;,&quot;step_type&quot;:&quot;none&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Encuesta\" aria-label=\"Encuesta\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"794\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"0b8c9f7\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"AUTOEVALUACI\u00d3N PREVIA - White Coat Med Spa\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"794\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_8b83a1b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-arrow-right\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-name elementor-col-100\">\n\t\t\t\t\t<h2> Este es su formulario de evaluci\u00f3n.<\/h2>\n<img decoding=\"async\" src=\"https:\/\/whitecoatmedspa.com\/wp-content\/uploads\/2023\/02\/home-banner-deskto-3.jpg\" alt=\"Banner para la encuesta\">\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_1610f16 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_82b44eb elementor-col-100\">\n\t\t\t\t\t<h2>1- Datos Personales<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2af4667 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2af4667\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre y Apellidos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2af4667]\" id=\"form-field-field_2af4667\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_cdd364c elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cdd364c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmail\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_cdd364c]\" id=\"form-field-field_cdd364c\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_20b2012 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_20b2012\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_20b2012]\" id=\"form-field-field_20b2012\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Solo se aceptan n\u00fameros y caracteres de tel\u00e9fono (#,-,*,etc).\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bf7bcca elementor-col-100\">\n\t\t\t\t\t<h2>2- Verificaci\u00f3n de edad<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_f84b58e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f84b58e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUsted certifica que es mayor de 18 a\u00f1os de edad?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Si\" id=\"form-field-field_f84b58e-0\" name=\"form_fields[field_f84b58e][]\"> <label for=\"form-field-field_f84b58e-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_f84b58e-1\" name=\"form_fields[field_f84b58e][]\"> <label for=\"form-field-field_f84b58e-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_63f7b44 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7511820 elementor-col-100\">\n\t\t\t\t\t<h2>3- \u00bfQu\u00e9 procedimiento le interesa? \ud83d\ude0d<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b1a0225 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lipoescultura\" id=\"form-field-field_b1a0225-0\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-0\">Lipoescultura<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aumento de senos\" id=\"form-field-field_b1a0225-1\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-1\">Aumento de senos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mommy Makeover\" id=\"form-field-field_b1a0225-2\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-2\">Mommy Makeover<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tummy Tuck (Abdominoplast\u00eda)\" id=\"form-field-field_b1a0225-3\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-3\">Tummy Tuck (Abdominoplast\u00eda)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Transferencia de grasa a los gl\u00fateos (BBL)\" id=\"form-field-field_b1a0225-4\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-4\">Transferencia de grasa a los gl\u00fateos (BBL)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Levantamiento de senos\" id=\"form-field-field_b1a0225-5\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-5\">Levantamiento de senos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Reducci\u00f3n de senos\" id=\"form-field-field_b1a0225-6\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-6\">Reducci\u00f3n de senos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rinoplastia\" id=\"form-field-field_b1a0225-7\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-7\">Rinoplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Liposucci\u00f3n en los brazos\" id=\"form-field-field_b1a0225-8\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-8\">Liposucci\u00f3n en los brazos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Liposucci\u00f3n en la parte interior de los muslos\" id=\"form-field-field_b1a0225-9\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-9\">Liposucci\u00f3n en la parte interior de los muslos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Otro procedimiento pero que no est\u00e1 listado\" id=\"form-field-field_b1a0225-10\" name=\"form_fields[field_b1a0225][]\"> <label for=\"form-field-field_b1a0225-10\">Otro procedimiento pero que no est\u00e1 listado<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_c90b4a6 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_226af5a elementor-col-100\">\n\t\t\t\t\t<h2>4- Su estatura en pies <\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_857bfa2 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_857bfa2]\" id=\"form-field-field_857bfa2\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Ejemplo 4&#039;6\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_dfd7fed elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_776d110 elementor-col-100\">\n\t\t\t\t\t<h2>5- Su peso actual en libras \u2696\ufe0f\n<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_96dce60 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_96dce60]\" id=\"form-field-field_96dce60\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_bffadad elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5b4be69 elementor-col-100\">\n\t\t\t\t\t<h2>6- Fecha de nacimiento \ud83c\udf82<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_a42a9b4 elementor-col-30\">\n\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_a42a9b4]\" id=\"form-field-field_a42a9b4\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" max=\"2008-04-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_26b2f88 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_4db758a elementor-col-100\">\n\t\t\t\t\t<h2>7- \u00bfFuma o consume algo que contenga nicotina? \ud83d\ude2e\u200d\ud83d\udca8\ud83d\udeac\ud83d\udca8\ud83c\udf3f<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_28146db elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"S\u00ed. Diariamente\" id=\"form-field-field_28146db-0\" name=\"form_fields[field_28146db][]\"> <label for=\"form-field-field_28146db-0\">S\u00ed. Diariamente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"S\u00ed. Menos de tres veces por semana\" id=\"form-field-field_28146db-1\" name=\"form_fields[field_28146db][]\"> <label for=\"form-field-field_28146db-1\">S\u00ed. Menos de tres veces por semana<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"S\u00ed. Soy fumadora pasiva\" id=\"form-field-field_28146db-2\" name=\"form_fields[field_28146db][]\"> <label for=\"form-field-field_28146db-2\">S\u00ed. Soy fumadora pasiva<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"S\u00ed. Fumo hookah\" id=\"form-field-field_28146db-3\" name=\"form_fields[field_28146db][]\"> <label for=\"form-field-field_28146db-3\">S\u00ed. Fumo hookah<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No. Nunca consumo nicotina\" id=\"form-field-field_28146db-4\" name=\"form_fields[field_28146db][]\"> <label for=\"form-field-field_28146db-4\">No. Nunca consumo nicotina<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_76e2a95 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_64f2bed elementor-col-100\">\n\t\t\t\t\t<h2>8- Es al\u00e9rgico \ud83e\udd27 o ha reaccionado adversamente a lo siguiente:<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_96ddb9a elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Aspirina\" id=\"form-field-field_96ddb9a-0\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-0\">Aspirina<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Iodo\" id=\"form-field-field_96ddb9a-1\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-1\">Iodo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Latex\" id=\"form-field-field_96ddb9a-2\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-2\">Latex<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lidocaina\" id=\"form-field-field_96ddb9a-3\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-3\">Lidocaina<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Penicilina u otros antibi\u00f3ticos\" id=\"form-field-field_96ddb9a-4\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-4\">Penicilina u otros antibi\u00f3ticos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Sulfamidas\" id=\"form-field-field_96ddb9a-5\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-5\">Sulfamidas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No tengo alergias\" id=\"form-field-field_96ddb9a-6\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-6\">No tengo alergias<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tengo alergias no contenidas en esta lista\" id=\"form-field-field_96ddb9a-7\" name=\"form_fields[field_96ddb9a][]\"> <label for=\"form-field-field_96ddb9a-7\">Tengo alergias no contenidas en esta lista<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_aa397b3 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_7b67c4f elementor-col-100\">\n\t\t\t\t\t<h2>9- Mencione cirug\u00edas que tuvo en el pasado y las fechas. \ud83e\udd15\u23f3\ud83c\udf51<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_b3116ec elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b3116ec\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIncluyendo cirug\u00edas pl\u00e1sticas y cualquier tipo de procedimiento quir\u00fargico.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_b3116ec]\" id=\"form-field-field_b3116ec\" rows=\"3\" placeholder=\"Escribe aqu\u00ed tu respuetsa\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_8335a8e elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_141fdbb elementor-col-100\">\n\t\t\t\t\t<h2>10- \u00bfTienes inyecci\u00f3n o implantes en los gl\u00fateos?<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_b0420e2 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Si\" id=\"form-field-field_b0420e2-0\" name=\"form_fields[field_b0420e2][]\"> <label for=\"form-field-field_b0420e2-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_b0420e2-1\" name=\"form_fields[field_b0420e2][]\"> <label for=\"form-field-field_b0420e2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e85e486 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_441e576 elementor-col-100\">\n\t\t\t\t\t<h2>11- \u00bfUsted padece\/ha padecido alguna de las siguientes enfermedades y\/o condiciones m\u00e9dicas? \ud83e\udd12\ud83e\udd22<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_9881c9b elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anemia\" id=\"form-field-field_9881c9b-0\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-0\">Anemia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asma\" id=\"form-field-field_9881c9b-1\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-1\">Asma<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anemia drepanoc\u00edtica\" id=\"form-field-field_9881c9b-2\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-2\">Anemia drepanoc\u00edtica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Accidentes cerebrovasculares\" id=\"form-field-field_9881c9b-3\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-3\">Accidentes cerebrovasculares<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ataque al coraz\u00f3n \/ infarto de miocardio\" id=\"form-field-field_9881c9b-4\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-4\">Ataque al coraz\u00f3n \/ infarto de miocardio<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"C\u00e1ncer activo o leucemia\" id=\"form-field-field_9881c9b-5\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-5\">C\u00e1ncer activo o leucemia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Convulsiones o Epilepsia\" id=\"form-field-field_9881c9b-6\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-6\">Convulsiones o Epilepsia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Desorden en la sangre\" id=\"form-field-field_9881c9b-7\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-7\">Desorden en la sangre<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes\" id=\"form-field-field_9881c9b-8\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-8\">Diabetes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fiebre Reumatoidea\" id=\"form-field-field_9881c9b-9\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-9\">Fiebre Reumatoidea<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Infecci\u00f3n viral cr\u00f3nica\" id=\"form-field-field_9881c9b-10\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-10\">Infecci\u00f3n viral cr\u00f3nica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hepatitis u otras enfermedades hep\u00e1ticas\" id=\"form-field-field_9881c9b-11\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-11\">Hepatitis u otras enfermedades hep\u00e1ticas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hipertensi\u00f3n arterial controlada\" id=\"form-field-field_9881c9b-12\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-12\">Hipertensi\u00f3n arterial controlada<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hipertensi\u00f3n arterial NO controlada\" id=\"form-field-field_9881c9b-13\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-13\">Hipertensi\u00f3n arterial NO controlada<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lupus\" id=\"form-field-field_9881c9b-14\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-14\">Lupus<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Marcapasos\" id=\"form-field-field_9881c9b-15\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-15\">Marcapasos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Enfermedad de tiroides\" id=\"form-field-field_9881c9b-16\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-16\">Enfermedad de tiroides<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"VIH\" id=\"form-field-field_9881c9b-17\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-17\">VIH<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Paciente de Cirug\u00eda Bari\u00e1trica\" id=\"form-field-field_9881c9b-18\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-18\">Paciente de Cirug\u00eda Bari\u00e1trica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"P\u00e9rdida de peso mayor a las 80 libras\" id=\"form-field-field_9881c9b-19\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-19\">P\u00e9rdida de peso mayor a las 80 libras<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hernia umbilical\" id=\"form-field-field_9881c9b-20\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-20\">Hernia umbilical<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"DVT or Blood Clot\" id=\"form-field-field_9881c9b-21\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-21\">DVT or Blood Clot<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Otra enfermedad\/condici\u00f3n no contenida en la lista\" id=\"form-field-field_9881c9b-22\" name=\"form_fields[field_9881c9b][]\"> <label for=\"form-field-field_9881c9b-22\">Otra enfermedad\/condici\u00f3n no contenida en la lista<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_00141f4 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6ee7199 elementor-col-100\">\n\t\t\t\t\t<h2>12- \u00bfEst\u00e1 tomando alg\u00fan medicamento recetado, de venta libre o vitaminas? \ud83d\udc8a<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_47306a9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_47306a9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi est\u00e1 tomando, por favor menci\u00f3nelos todos.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_47306a9]\" id=\"form-field-field_47306a9\" rows=\"4\" placeholder=\"Escribe aqu\u00ed tu respuetsa\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_9e57cd6 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_6a692f6 elementor-col-100\">\n\t\t\t\t\t<h2>13- \u00bfEst\u00e1s amamantando actualmente?<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_d31ab04 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Si\" id=\"form-field-field_d31ab04-0\" name=\"form_fields[field_d31ab04][]\"> <label for=\"form-field-field_d31ab04-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_d31ab04-1\" name=\"form_fields[field_d31ab04][]\"> <label for=\"form-field-field_d31ab04-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e632b0b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_15ba404 elementor-col-100\">\n\t\t\t\t\t<h2>14- \u00bfEst\u00e1 usando actualmente alg\u00fan m\u00e9todo anticonceptivo, p\u00edldoras, DIU, shots, Nexplanon, NuvaRing? \ud83d\uded1<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_3a98a79 elementor-col-100\">\n\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Si\" id=\"form-field-field_3a98a79-0\" name=\"form_fields[field_3a98a79][]\"> <label for=\"form-field-field_3a98a79-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"No\" id=\"form-field-field_3a98a79-1\" name=\"form_fields[field_3a98a79][]\"> <label for=\"form-field-field_3a98a79-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_b350833 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_230a355 elementor-col-100\">\n\t\t\t\t\t<h2>15- Enumere todas las fechas de embarazos, abortos espont\u00e1neos e interrupciones de embarazos que ha experimentado. \ud83d\udccb<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_db1dcc9 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_db1dcc9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSi esto no aplica parta usted, por favor vaya a la siguiente p\u00e1gina.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_db1dcc9]\" id=\"form-field-field_db1dcc9\" rows=\"4\" placeholder=\"Escribe aqu\u00ed tu respuetsa\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_fb6b640 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0795a24 elementor-col-100\">\n\t\t\t\t\t<h2>16- \u00bfCu\u00e1ntos hijos tiene?<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a271fab elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a271fab]\" id=\"form-field-field_a271fab\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_174bd4c elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8fe3381 elementor-col-100\">\n\t\t\t\t\t<h2>17- \u00bfCu\u00e1ndo fue su \u00faltimo ciclo menstrual?<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_9faa9a0 elementor-col-30\">\n\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_9faa9a0]\" id=\"form-field-field_9faa9a0\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_b1cc914 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a5c19b1 elementor-col-100\">\n\t\t\t\t\t<h2>18- \u00bfTienes alg\u00fan m\u00e9dico en mente o necesitas la recomendaci\u00f3n de uno de nuestros expertos para elegir a tu cirujano? \ud83d\udc68\ud83c\udffe\u200d\u2695\ufe0f\ud83d\udc89\ud83d\udc68\ud83c\udffb\u200d\u2695\ufe0f\u2695\ufe0f<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e6ef51e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e6ef51e]\" id=\"form-field-field_e6ef51e\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Escribe aqu\u00ed tu respuetsa\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_164c40a elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_27299da elementor-col-100\">\n\t\t\t\t\t<h2>19- \u00bfCu\u00e1l es su fecha de cirug\u00eda deseada?<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_4ab1c6f elementor-col-30\">\n\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_4ab1c6f]\" id=\"form-field-field_4ab1c6f\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_fbab032 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8bb1482 elementor-col-100\">\n\t\t\t\t\t<h2>20- Recuerde: tenemos opciones de Financiamiento disponibles. Le interesa aplicar? \ud83d\udcb5<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_719e108 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_719e108\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOfrecemos financiamiento propio y tambi\u00e9n trabajamos con Care Credit, Alphaeon, y United Medical Credit.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"S\u00ed! Me encantar\u00eda.\" id=\"form-field-field_719e108-0\" name=\"form_fields[field_719e108][]\"> <label for=\"form-field-field_719e108-0\">S\u00ed! Me encantar\u00eda.<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pagar\u00e9 en efectivo\" id=\"form-field-field_719e108-1\" name=\"form_fields[field_719e108][]\"> <label for=\"form-field-field_719e108-1\">Pagar\u00e9 en efectivo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pagar\u00e9 con tarjeta\" id=\"form-field-field_719e108-2\" name=\"form_fields[field_719e108][]\"> <label for=\"form-field-field_719e108-2\">Pagar\u00e9 con tarjeta<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_17c1960 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_cb348af elementor-col-100\">\n\t\t\t\t\t<h2>21- Si tiene preguntas o comentarios adicionales, d\u00e9jenos saber. \u2705<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_6d4ee5e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d4ee5e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEstamos aqu\u00ed para ayudarle!\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-md\" name=\"form_fields[field_6d4ee5e]\" id=\"form-field-field_6d4ee5e\" rows=\"4\" placeholder=\"Escribe tu respuesta aqu\u00ed\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_4754c74 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2636ec1 elementor-col-100\">\n\t\t\t\t\t<h2>22- Entiendo y acepto la informaci\u00f3n indicada anteriormente. Entiendo que ser\u00e9 aceptado o no para la cirug\u00eda seg\u00fan la evaluaci\u00f3n de mi caso por parte del cirujano.<\/2>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_0473bcc elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0473bcc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPor favor, indique si acepta enviar la informaci\u00f3n para que el cirujano la eval\u00fae. Si no acepta, el cirujano no recibir\u00e1 la informaci\u00f3n para evaluarla.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yo acepto\" id=\"form-field-field_0473bcc-0\" name=\"form_fields[field_0473bcc][]\"> <label for=\"form-field-field_0473bcc-0\">Yo acepto<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Yo no acepto\" id=\"form-field-field_0473bcc-1\" name=\"form_fields[field_0473bcc][]\"> <label for=\"form-field-field_0473bcc-1\">Yo no acepto<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0316d2e elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_33eab8e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_33eab8e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHaz click en el bot\u00f3n para subir tus fotograf\u00edas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_33eab8e]\" id=\"form-field-field_33eab8e\" class=\"elementor-field elementor-size-md  elementor-upload-field\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-794","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - 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