{"id":1034,"date":"2023-01-25T16:38:00","date_gmt":"2023-01-26T00:38:00","guid":{"rendered":"https:\/\/drnicolasleyva.com\/consulta-virtual\/"},"modified":"2026-02-23T15:36:56","modified_gmt":"2026-02-23T23:36:56","slug":"consulta-virtual","status":"publish","type":"page","link":"https:\/\/drnicolasleyva.com\/es\/consulta-virtual\/","title":{"rendered":"Consulta virtual"},"content":{"rendered":"[vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#f4f1ed&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;6%&#8221; bottom_padding=&#8221;3%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<h6>CONSULTA VIRTUAL GRATUITA<\/h6>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#f4f1ed&#8221; scene_position=&#8221;center&#8221; bottom_padding=&#8221;4%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; 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border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_row_inner column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; top_padding=&#8221;5%&#8221; bottom_padding=&#8221;5%&#8221; left_padding_desktop=&#8221;5%&#8221; right_padding_desktop=&#8221;5%&#8221; text_align=&#8221;left&#8221; row_position=&#8221;default&#8221; row_position_tablet=&#8221;inherit&#8221; row_position_phone=&#8221;inherit&#8221; overflow=&#8221;visible&#8221; pointer_events=&#8221;all&#8221; class=&#8221;cuadro_blanco&#8221;][vc_column_inner column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; overflow=&#8221;visible&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/2&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text css=&#8221;.vc_custom_1676422854715{margin-bottom: 10px !important;}&#8221;]\n<p class=\"tipo-tomorrow-medium tipo-26\">GRATIS<\/p>\n[\/vc_column_text][vc_column_text]\n<h6>Consulta virtual<\/h6>\n[\/vc_column_text][\/vc_column_inner][vc_column_inner column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; overflow=&#8221;visible&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/2&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][divider line_type=&#8221;No Line&#8221; custom_height=&#8221;20&#8243;][vc_column_text css=&#8221;&#8221; text_direction=&#8221;default&#8221;]\u00a1Comience su viaje que le cambiar\u00e1 la vida! \u00a1Complete una consulta virtual gratuita con el Dr. Nico![\/vc_column_text][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#f4f1ed&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;4%&#8221; bottom_padding=&#8221;6%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;padding-5-percent&#8221; column_padding_tablet=&#8221;no-extra-padding&#8221; column_padding_phone=&#8221;no-extra-padding&#8221; column_padding_position=&#8221;left&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/2&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221; column_padding_type=&#8221;default&#8221; gradient_type=&#8221;default&#8221;][divider line_type=&#8221;No Line&#8221; custom_height=&#8221;0&#8243; custom_height_phone=&#8221;40&#8243;][vc_column_text]\n<p class=\"tipo-tomorrow-medium tipo-19\">ANTES DE EMPEZAR[\/vc_column_text][vc_column_text]\u00a1Por su seguridad!<\/p>\n<p>Rellene su formulario de historial m\u00e9dico con el mayor<br \/>\ndetalle posible. Esto ayudar\u00e1 a nuestro personal m\u00e9dico a<br \/>\ndeterminar si usted es un buen candidato<br \/>\npara la cirug\u00eda.<\/p>\n<p>Env\u00ede sus fotograf\u00edas siguiendo las<br \/>\ndirectrices correspondientes. Esto ayudar\u00e1 al Dr. Nico a determinar<br \/>\nlas mejores opciones quir\u00fargicas para usted. [\/vc_column_text][\/vc_column][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/2&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][divider line_type=&#8221;No Line&#8221; custom_height=&#8221;0&#8243; custom_height_phone=&#8221;40&#8243;][vc_column_text]\n<p class=\"tipo-tomorrow-medium tipo-19\">LA SEGURIDAD ES LO PRIMERO<\/p>\n[\/vc_column_text][vc_column_text]La cirug\u00eda pl\u00e1stica es principalmente un procedimiento electivo,<br \/>\n\u00a1pero sigue siendo una cirug\u00eda real!<\/p>\n<p>Por esta raz\u00f3n, el historial m\u00e9dico y la salud general<br \/>\ndel paciente se tienen en cuenta para<br \/>\ndeterminar su idoneidad para la cirug\u00eda.<\/p>\n<p>Algunas directrices generales pueden incluir:<\/p>\n<p>\u2022 IMC de 31 o menos<br \/>\n\u2022 No fumadores<br \/>\n\u2022 Buena salud f\u00edsica[\/vc_column_text][divider line_type=&#8221;No Line&#8221; custom_height=&#8221;0&#8243; custom_height_phone=&#8221;15&#8243;][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#ffffff&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;6%&#8221; bottom_padding=&#8221;6%&#8221; top_padding_phone=&#8221;10%&#8221; bottom_padding_phone=&#8221;10%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; class=&#8221;ocultarenmovil&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/4&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<p class=\"tipo-tomorrow-regular tipo-51\" style=\"color: #f6bd9c;\">01<\/p>\n[\/vc_column_text][vc_column_text]\n<h4>Rellenar el formulario<\/h4>\n[\/vc_column_text][\/vc_column][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/4&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<p class=\"tipo-tomorrow-regular tipo-51\" style=\"color: #f6bd9c;\">02<\/p>\n[\/vc_column_text][vc_column_text]\n<h4>Enviar<br \/>\nformulario<\/h4>\n[\/vc_column_text][\/vc_column][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/4&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<p class=\"tipo-tomorrow-regular tipo-51\" style=\"color: #f6bd9c;\">03<\/p>\n[\/vc_column_text][vc_column_text]\n<h4>Confirmaci\u00f3n por<br \/>\ncorreo electr\u00f3nico<\/h4>\n[\/vc_column_text][\/vc_column][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/4&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<p class=\"tipo-tomorrow-regular tipo-51\" style=\"color: #f6bd9c;\">04<\/p>\n[\/vc_column_text][vc_column_text css=&#8221;&#8221; text_direction=&#8221;default&#8221;]\n<h4>Comentarios<br \/>\ny presupuesto<\/h4>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#ffffff&#8221; scene_position=&#8221;center&#8221; bottom_padding=&#8221;4%&#8221; top_padding_phone=&#8221;15%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<p style=\"font-size: 19px;\">Este formulario es por su propia seguridad, para que nuestro cirujano pueda evaluar qu\u00e9 cirug\u00eda es una buena soluci\u00f3n para que usted alcance sus objetivos.<\/p>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#ffffff&#8221; scene_position=&#8221;center&#8221; bottom_padding=&#8221;6%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; class=&#8221;forma-virtualconsultation&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_direction_desktop=&#8221;default&#8221; column_element_spacing=&#8221;default&#8221; desktop_text_alignment=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_backdrop_filter=&#8221;none&#8221; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]<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 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class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/1034#gf_2' data-formid='2' novalidate><div id='gf_page_steps_2' class='gf_page_steps'><div id='gf_step_2_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Informaci\u00f3n de contacto<\/span><\/div><div id='gf_step_2_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Informaci\u00f3n Personal<\/span><\/div><div id='gf_step_2_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Historial M\u00e9dico<\/span><\/div><div id='gf_step_2_4' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Fotos<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_2_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n de contacto<\/h3><\/div><fieldset id=\"field_2_8\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_2_8'>\n                            \n                            <span id='input_2_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.3' id='input_2_8_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_8_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_8.6' id='input_2_8_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_8_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_107\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_107'>Correo electr\u00f3nico<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_107' id='input_2_107' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter orientacion gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Genero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_2_6' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Por favor selecciona' >Por favor selecciona<\/option><option value='Mujer' >MujerMujer<\/option><option value='Hombre' >Hombre<\/option><option value='Otro' >Otro<\/option><\/select><\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Etnia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>OCUPACI\u00d3N<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_2_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Edad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_16' id='input_2_16' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'>FECHA DE NACIMIENTO<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_17' id='input_2_17' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_2_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_2_17_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_17' class='gform_hidden' value='https:\/\/drnicolasleyva.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>DOMICILIO<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'>CIUDAD<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_2_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>ESTADO<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_2_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>CODIGO POSTAL<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_28' id='input_2_28' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_30\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_30'>TEL\u00c9FONO<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_2_30' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-third paises gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PA\u00cdS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_2_23' >\n                        <input type='hidden' class='gform_hidden' name='input_23.4' id='input_2_23_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_2_23_6_container' >\n                                        <select name='input_23.6' id='input_2_23_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/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='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_2_23_6' id='input_2_23_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_2_1' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='SIGUIENTE'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_2' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">INFORMACI\u00d3N PERSONAL<\/h3><\/div><div id=\"field_2_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_31'>ESTADO CIVIL<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHAS ESTADO EMBARAZADA?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_32'>\n\t\t\t<div class='gchoice gchoice_2_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='SI'  id='choice_2_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_32_0' id='label_2_32_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='NO'  id='choice_2_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_32_1' id='label_2_32_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'>ANTICONCEPTIVO UTILIZADO<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_2_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-quarter gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEST\u00c1S ACTUALMENTE EMBARAZADA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_34'>\n\t\t\t<div class='gchoice gchoice_2_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='SI'  id='choice_2_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_0' id='label_2_34_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='NO'  id='choice_2_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_34_1' id='label_2_34_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_35'>ESTATURA (PIES)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_2_35' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'>ESTATURA (PULGADAS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_37'>PESO ACTUAL (LIBRAS)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_2_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'>IMC (\u00cdNDICE DE MASA CORPORAL)<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_52'>\u00bfCU\u00c1L ES TU TIPO DE SANGRE?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'>LIBRAS PERDIDAS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_2_39' type='text' value='' class='large'    placeholder='\u00bfCu\u00e1ntas libras has perdido?' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>PROCEDIMIENTO(S) DE CIRUG\u00cdA PL\u00c1STICA QUE TE INTERESAN<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_2_40' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><li class=\"gfmc-column gfmc-column50 gfmc-row-1-column gfmc-row-1-col-1-of-2\"><ul class=\"flex-wrapper flex-wrapper-2\"><fieldset id=\"field_2_113\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHAS TENIDO CIRUG\u00cdA PL\u00c1STICA ANTERIORMENTE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_113'>\n\t\t\t<div class='gchoice gchoice_2_113_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='SI'  id='choice_2_113_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_113_0' id='label_2_113_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_113_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_113' type='radio' value='NO'  id='choice_2_113_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_113_1' id='label_2_113_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_47\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>\u00bfQU\u00c9 CIRUG\u00cdAS PL\u00c1STICAS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_47' id='input_2_47' class='textarea large'    placeholder='Enumera los procedimientos que has tenido junto con la fecha en que se realizaron (mes y a\u00f1o).' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_114\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHAS TENIDO ALGUNA OTRA CIRUG\u00cdA PREVIA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_114'>\n\t\t\t<div class='gchoice gchoice_2_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='SI'  id='choice_2_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_114_0' id='label_2_114_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='NO'  id='choice_2_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_114_1' id='label_2_114_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_112'>\u00bfQU\u00c9 CIRUG\u00cdAS PREVIAS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_2_112' class='textarea large'    placeholder='Manga g\u00e1strica, Bypass, Banda g\u00e1strica, Ves\u00edcula biliar, Ap\u00e9ndice, Hernia, Histerectom\u00eda, Ces\u00e1rea u otra cirug\u00eda, por favor indica el mes y el a\u00f1o de la cirug\u00eda' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/ul><\/li><li class=\"gfmc-column gfmc-column50 gfmc-row-1-column gfmc-row-1-col-2-of-2\"><ul class=\"flex-wrapper flex-wrapper-2\"><fieldset id=\"field_2_115\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHAS TENIDO CIRUG\u00cdA DE P\u00c9RDIDA DE PESO ANTERIORMENTE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_115'>\n\t\t\t<div class='gchoice gchoice_2_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='SI'  id='choice_2_115_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_115_0' id='label_2_115_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='NO'  id='choice_2_115_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_115_1' id='label_2_115_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_51'>\u00bfCU\u00c1NDO FUE TU CIRUG\u00cdA DE P\u00c9RDIDA DE PESO?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='large'    placeholder='Por favor indica el mes y el a\u00f1o de la cirug\u00eda'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_55\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHAS TENIDO AUMENTO DE BUSTO ANTERIORMENTE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_55'>\n\t\t\t<div class='gchoice gchoice_2_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='SI'  id='choice_2_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_55_0' id='label_2_55_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='NO'  id='choice_2_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_55_1' id='label_2_55_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_116\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_116'>\u00bfCU\u00c1NDO FUE TU CIRUG\u00cdA DE AUMENTO DE BUSTO?<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_2_116' type='text' value='' class='large'    placeholder='Por favor indica el mes y el a\u00f1o de la cirug\u00eda'  aria-invalid=\"false\"   \/><\/div><\/div><\/ul><\/li><div id=\"field_2_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_56'>TALLA DE BUSTO ACTUAL<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_57'>TALLA DE BUSTO DESEADA<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_59\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >NOMBRE DEL CONTACTO DE EMERGENCIA<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_2_59'>\n                            \n                            <span id='input_2_59_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_59.3' id='input_2_59_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_59_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_59_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_59.6' id='input_2_59_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_59_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_60'>N\u00daMERO DE TEL\u00c9FONO DE EMERGENCIA<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_61'>CIUDAD \/ ESTADO DEL CONTACTO DE EMERGENCIA<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_2_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_66\" 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_below field_validation_below gfield_visibility_visible\"  ><div class=\"pb-md\"><\/div> <p class=\"tipo-tomorrow-medium tipo-19 pb-sm\">Autorizaci\u00f3n de divulgaci\u00f3n al contacto de emergencia *<\/p> <p>\u00bfAutorizas que brindemos informaci\u00f3n sobre ti y tu salud en relaci\u00f3n con la cirug\u00eda a tu contacto de emergencia en caso de una emergencia?<\/p><\/div><fieldset id=\"field_2_68\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_68.1' id='input_2_68_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_68_1' >Autorizo que se brinde informaci\u00f3n sobre m\u00ed y mi salud a mi contacto de emergencia en caso de una emergencia.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_68.2' value='Autorizo que se brinde informaci\u00f3n sobre m\u00ed y mi salud a mi contacto de emergencia en caso de una emergencia.' class='gform_hidden' \/><input type='hidden' name='input_68.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_69' 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_2_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_3' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Historial M\u00e9dico<\/h3><\/div><fieldset id=\"field_2_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTIENES ANTECEDENTES DE ENFERMEDAD O ALGUNA CONDICI\u00d3N M\u00c9DICA SUBYACENTE?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_81'>\n\t\t\t<div class='gchoice gchoice_2_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='SI'  id='choice_2_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_81_0' id='label_2_81_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='NO'  id='choice_2_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_81_1' id='label_2_81_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_106\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_106'>POR FAVOR EXPLICA TU CONDICI\u00d3N M\u00c9DICA<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_2_106' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_2col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfANTECEDENTES DE CONDICI\u00d3N MENTAL, ENFERMEDAD (PSIQUI\u00c1TRICA) O DOLOR CR\u00d3NICO?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_77'>\n\t\t\t<div class='gchoice gchoice_2_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='NINGUNO'  id='choice_2_77_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_0' id='label_2_77_0' class='gform-field-label gform-field-label--type-inline'>NINGUNO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='FIBROMIALGIA'  id='choice_2_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_1' id='label_2_77_1' class='gform-field-label gform-field-label--type-inline'>FIBROMIALGIA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='DEPRESI\u00d3N'  id='choice_2_77_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_2' id='label_2_77_2' class='gform-field-label gform-field-label--type-inline'>DEPRESI\u00d3N<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='ANSIEDAD'  id='choice_2_77_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_3' id='label_2_77_3' class='gform-field-label gform-field-label--type-inline'>ANSIEDAD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='ATAQUES DE P\u00c1NICO'  id='choice_2_77_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_4' id='label_2_77_4' class='gform-field-label gform-field-label--type-inline'>ATAQUES DE P\u00c1NICO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='TRASTORNO OBSESIVO COMPULSIVO (TOC)'  id='choice_2_77_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_5' id='label_2_77_5' class='gform-field-label gform-field-label--type-inline'>TRASTORNO OBSESIVO COMPULSIVO (TOC)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='TRASTORNOS DE LA PERSONALIDAD'  id='choice_2_77_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_6' id='label_2_77_6' class='gform-field-label gform-field-label--type-inline'>TRASTORNOS DE LA PERSONALIDAD<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_77_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='gf_other_choice'  id='choice_2_77_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_77_7' id='label_2_77_7' class='gform-field-label gform-field-label--type-inline'>Otro<\/label><br \/><input id='input_2_77_other' class='gchoice_other_control' name='input_77_other' type='text' value='Otro' aria-label='Si es otro, especif\u00edcalo, por favor'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTIENES ANTECEDENTES DE TROMBOSIS EN TU FAMILIA?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_78'>\n\t\t\t<div class='gchoice gchoice_2_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='SI'  id='choice_2_78_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_78_0' id='label_2_78_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='NO'  id='choice_2_78_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_78_1' id='label_2_78_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_122\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTOMAS MEDICAMENTOS PARA EL DOLOR CR\u00d3NICO (NARC\u00d3TICOS \/ OPIOIDES)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_122'>\n\t\t\t<div class='gchoice gchoice_2_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='SI'  id='choice_2_122_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_122\"   \/>\n\t\t\t\t\t<label for='choice_2_122_0' id='label_2_122_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='NO'  id='choice_2_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_122_1' id='label_2_122_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_2_122'>Si la respuesta es s\u00ed, an\u00f3talos abajo.<\/div><\/fieldset><fieldset id=\"field_2_80\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTOMAS ANTIDEPRESIVOS, PASTILLAS PARA LA ANSIEDAD O PASTILLAS PARA DORMIR?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_80'>\n\t\t\t<div class='gchoice gchoice_2_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='SI'  id='choice_2_80_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_80\"   \/>\n\t\t\t\t\t<label for='choice_2_80_0' id='label_2_80_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='NO'  id='choice_2_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_80_1' id='label_2_80_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_2_80'>Si la respuesta es s\u00ed, an\u00f3talos abajo.<\/div><\/fieldset><div id=\"field_2_73\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_73'>POR FAVOR ENUMERA TODOS LOS MEDICAMENTOS Y PARA QU\u00c9 LOS TOMAS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_73' id='input_2_73' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_74\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_74'>POR FAVOR ENUMERA CUALQUIER SUPLEMENTO QUE TOMES<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_74' id='input_2_74' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_75\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_75'>POR FAVOR ENUMERA CUALQUIER ALERGIA IMPORTANTE QUE TENGAS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_75' id='input_2_75' class='textarea small'    placeholder='es decir, medicamentos, alimentos, materiales o alergias ambientales.' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_79'>\u00bfTIENES ALGUNA DIETA ESPECIAL?<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_2_79' type='text' value='' class='large'    placeholder='es decir, vegano, sin gluten, etc.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_82\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfUSAS DROGAS RECREATIVAS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_82'>\n\t\t\t<div class='gchoice gchoice_2_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='SI'  id='choice_2_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_0' id='label_2_82_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='NO'  id='choice_2_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_82_1' id='label_2_82_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_83'>\u00bfQu\u00e9 drogas recreativas usas y con qu\u00e9 frecuencia?<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_2_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_84\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfFUMAS CIGARRILLOS?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_84'>\n\t\t\t<div class='gchoice gchoice_2_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='SI'  id='choice_2_84_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_84_0' id='label_2_84_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='NO'  id='choice_2_84_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_84_1' id='label_2_84_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_84_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='DEJ\u00c9 DE FUMAR'  id='choice_2_84_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_84_2' id='label_2_84_2' class='gform-field-label gform-field-label--type-inline'>DEJ\u00c9 DE FUMAR<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_110'>\u00bfCu\u00e1ndo dejaste de fumar?<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_2_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_121\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_121'>\u00bfCu\u00e1nto y con qu\u00e9 frecuencia fumas?<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_2_121' type='text' value='' class='large'    placeholder='es decir, 3 veces al d\u00eda, todos los d\u00edas.'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_85\" 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_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfBEBES ALCOHOL?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_85'>\n\t\t\t<div class='gchoice gchoice_2_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='SI'  id='choice_2_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_0' id='label_2_85_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='NO'  id='choice_2_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_85_1' id='label_2_85_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_86\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_86'>\u00bfCU\u00c1NTO Y CON QU\u00c9 FRECUENCIA BEBES?<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_2_86' type='text' value='' class='large'    placeholder='2-3 veces por mes'  aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_2_87\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTIENES AL MENOS UN ESQUEMA COMPLETO DE VACUNACI\u00d3N CONTRA EL COVID-19?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_87'>\n\t\t\t<div class='gchoice gchoice_2_87_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='SI'  id='choice_2_87_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_2_87\"   \/>\n\t\t\t\t\t<label for='choice_2_87_0' id='label_2_87_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_87_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_87' type='radio' value='NO'  id='choice_2_87_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_87_1' id='label_2_87_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_2_87'>(la respuesta a esta pregunta no afectar\u00e1 tu evaluaci\u00f3n)<\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_2_91' 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_2_91' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_2_4' class='gform_page' data-js='page-field-id-91' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_2_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_92\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Fotos<\/h3><\/div><div id=\"field_2_93\" 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_below field_validation_below gfield_visibility_visible\"  ><p>Estas fotos ser\u00e1n cargadas y enviadas de forma segura a tu coordinador con el prop\u00f3sito de calificarte para tu procedimiento quir\u00fargico.<\/p> <p class=\"tipo-tomorrow-medium pb-sm\">Por favor lee antes de enviar fotos:<\/p> <ul class=\"mb-sm\"> <li class=\"pb-sm\">Si env\u00edas fotos faciales, incluye frente y ambos lados del rostro.<\/li> <li class=\"pb-sm\">Para procedimientos no faciales, las fotos deben ser <b>sin ropa<\/b> (tambi\u00e9n sin ropa interior) para que el Dr. Nico pueda hacer una evaluaci\u00f3n precisa de tu caso. Puedes cubrir tu rostro o tomar las fotos de los hombros hacia abajo, as\u00ed como cubrir tus \u00e1reas \u00edntimas con un emoji si eso te hace sentir m\u00e1s c\u00f3modo.<\/li> <\/ul> <div class=\"pb-sm\">Los \u00e1ngulos que necesitamos son:<\/div><\/div><div id=\"field_2_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Para liposucci\u00f3n de papada\n(solo cuando se realiza\njunto con cirug\u00edas mayores):<\/b>\n\n<div class=\"pb-sm\"><\/div> - Frente<br> - Ambos lados<br><\/div><div id=\"field_2_118\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Para procedimientos de torso, abdomen y zona gl\u00fatea:<\/b>\n\n<div class=\"pb-sm\"><\/div> - Frente<br> - Ambos lados<br> - Espalda<br><\/div><div id=\"field_2_119\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Para procedimientos de brazos:<\/b>\n<div class=\"pb-sm\"><\/div> Frente y espalda, con los brazos hacia los lados y los codos flexionados hacia arriba en un \u00e1ngulo de 90 grados.<\/div><div id=\"field_2_120\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-quarter gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><b>Para procedimientos de muslos:<\/b>\n<div class=\"pb-sm\"><\/div> Frente y espalda, de pie con las piernas ligeramente abiertas.<\/div><div id=\"field_2_123\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_2_124\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sube tus fotos<\/h3><\/div><div id=\"field_2_95\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_95'>VISTA FRONTAL<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='1048576000' \/><input name='input_95' id='input_2_95' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_95\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_95'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_95'><\/div> <\/div><\/div><div id=\"field_2_94\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_94'>VISTA LATERAL<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_94' id='input_2_94' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_94\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_94'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_94'><\/div> <\/div><\/div><div id=\"field_2_96\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_96'>OTRA VISTA LATERAL<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_96' id='input_2_96' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_96\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_96'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_96'><\/div> <\/div><\/div><div id=\"field_2_97\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_97'>ESPALDA (SI APLICA)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_97' id='input_2_97' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_97\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_97'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_97'><\/div> <\/div><\/div><div id=\"field_2_99\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_99'>BRAZOS (SI APLICA)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_99' id='input_2_99' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_99\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_99'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_99'><\/div> <\/div><\/div><div id=\"field_2_100\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_100'>ROSTRO FRENTE (SI APLICA)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_100' id='input_2_100' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_100\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_100'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_100'><\/div> <\/div><\/div><div id=\"field_2_98\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_98'>ROSTRO IZQUIERDA (SI APLICA)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_98' id='input_2_98' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_98\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_98'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_98'><\/div> <\/div><\/div><div id=\"field_2_101\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_101'>ROSTRO DERECHA (SI APLICA)<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='1048576000' \/><input name='input_101' id='input_2_101' type='file' class='large' aria-describedby=\"gfield_upload_rules_2_101\" onchange='javascript:gformValidateFileSize( this, 1048576000 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_2_101'>Tama\u00f1o m\u00e1ximo de archivo: 1,000 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_2_101'><\/div> <\/div><\/div><div id=\"field_2_102\" 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_below field_validation_below gfield_visibility_visible\"  ><div class=\"pb-md\"><\/div> <p class=\"tipo-tomorrow-medium pb-sm\">T\u00c9RMINOS Y CONDICIONES *<\/p> <p class=\"pb-sm-i\">Entiendo que la divulgaci\u00f3n completa es necesaria para mi seguridad m\u00e9dica. He llenado este historial m\u00e9dico lo mejor de mi conocimiento y he respondido estas preguntas con total honestidad para asegurar mi salud y seguridad.<\/p><\/div><fieldset id=\"field_2_104\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_104.1' id='input_2_104_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_104_1' >Acepto los T\u00e9rminos y Condiciones.<span 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gform-field-label--type-inline gfield_consent_label\" for='input_2_105_1' >He le\u00eddo y acepto los t\u00e9rminos de servicio y la pol\u00edtica de privacidad.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_105.2' value='He le\u00eddo y acepto los t\u00e9rminos de servicio y la pol\u00edtica de privacidad.' class='gform_hidden' \/><input type='hidden' name='input_105.3' value='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_125\" class=\"gfield gfield--type-turnstile gfield--input-type-turnstile gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_turnstile'><div class=\"cf-turnstile\" id=\"cf-turnstile_2\" data-js-turnstile data-response-field-name=\"cf-turnstile-response_2\" data-theme=\"auto\" data-size=\"\" 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