{"id":325,"date":"2026-01-13T14:37:55","date_gmt":"2026-01-13T19:37:55","guid":{"rendered":"https:\/\/register.advocatero.com\/?page_id=325"},"modified":"2026-04-01T16:45:31","modified_gmt":"2026-04-01T20:45:31","slug":"patient-registration-advocate-radiation-oncology","status":"publish","type":"page","link":"https:\/\/register.advocatero.com\/es\/","title":{"rendered":"Patient Registration &#8211; Advocate Radiation Oncology"},"content":{"rendered":"<div data-elementor-type=\"wp-post\" data-elementor-id=\"325\" class=\"elementor elementor-325\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2e156d2 e-flex e-con-boxed e-con e-parent\" data-id=\"2e156d2\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b4730a0 elementor-widget elementor-widget-image\" data-id=\"b4730a0\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"537\" height=\"158\" src=\"https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo.png\" class=\"attachment-large size-large wp-image-5\" alt=\"Advocate Radiation Oncology Logo for Website\" srcset=\"https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo.png 537w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-300x88.png 300w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-200x59.png 200w, https:\/\/register.advocatero.com\/wp-content\/uploads\/2020\/02\/Advocate-Radiation-Oncology-Logo-400x118.png 400w\" sizes=\"(max-width: 537px) 100vw, 537px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-e55ca5f e-con-full e-flex e-con e-child\" data-id=\"e55ca5f\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-30fd2c9 e-con-full e-flex e-con e-child\" data-id=\"30fd2c9\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a38eb39 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"a38eb39\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/advocatero.com\/wp-content\/uploads\/2026\/03\/426-PHS-SPANISH-PATIENT-REGISTRATION-PACKAGE.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-pdf\" viewbox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M181.9 256.1c-5-16-4.9-46.9-2-46.9 8.4 0 7.6 36.9 2 46.9zm-1.7 47.2c-7.7 20.2-17.3 43.3-28.4 62.7 18.3-7 39-17.2 62.9-21.9-12.7-9.6-24.9-23.4-34.5-40.8zM86.1 428.1c0 .8 13.2-5.4 34.9-40.2-6.7 6.3-29.1 24.5-34.9 40.2zM248 160h136v328c0 13.3-10.7 24-24 24H24c-13.3 0-24-10.7-24-24V24C0 10.7 10.7 0 24 0h200v136c0 13.2 10.8 24 24 24zm-8 171.8c-20-12.2-33.3-29-42.7-53.8 4.5-18.5 11.6-46.6 6.2-64.2-4.7-29.4-42.4-26.5-47.8-6.8-5 18.3-.4 44.1 8.1 77-11.6 27.6-28.7 64.6-40.8 85.8-.1 0-.1.1-.2.1-27.1 13.9-73.6 44.5-54.5 68 5.6 6.9 16 10 21.5 10 17.9 0 35.7-18 61.1-61.8 25.8-8.5 54.1-19.1 79-23.2 21.7 11.8 47.1 19.5 64 19.5 29.2 0 31.2-32 19.7-43.4-13.9-13.6-54.3-9.7-73.6-7.2zM377 105L279 7c-4.5-4.5-10.6-7-17-7h-6v128h128v-6.1c0-6.3-2.5-12.4-7-16.9zm-74.1 255.3c4.1-2.7-2.5-11.9-42.8-9 37.1 15.8 42.8 9 42.8 9z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Formulario de registro<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a3df289 e-con-full e-flex e-con e-child\" data-id=\"a3df289\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3dbc9d6 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"3dbc9d6\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/advocatero.com\/wp-content\/uploads\/2026\/04\/PHS-New-Patient-Registration-Form.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-file-pdf\" viewbox=\"0 0 384 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M181.9 256.1c-5-16-4.9-46.9-2-46.9 8.4 0 7.6 36.9 2 46.9zm-1.7 47.2c-7.7 20.2-17.3 43.3-28.4 62.7 18.3-7 39-17.2 62.9-21.9-12.7-9.6-24.9-23.4-34.5-40.8zM86.1 428.1c0 .8 13.2-5.4 34.9-40.2-6.7 6.3-29.1 24.5-34.9 40.2zM248 160h136v328c0 13.3-10.7 24-24 24H24c-13.3 0-24-10.7-24-24V24C0 10.7 10.7 0 24 0h200v136c0 13.2 10.8 24 24 24zm-8 171.8c-20-12.2-33.3-29-42.7-53.8 4.5-18.5 11.6-46.6 6.2-64.2-4.7-29.4-42.4-26.5-47.8-6.8-5 18.3-.4 44.1 8.1 77-11.6 27.6-28.7 64.6-40.8 85.8-.1 0-.1.1-.2.1-27.1 13.9-73.6 44.5-54.5 68 5.6 6.9 16 10 21.5 10 17.9 0 35.7-18 61.1-61.8 25.8-8.5 54.1-19.1 79-23.2 21.7 11.8 47.1 19.5 64 19.5 29.2 0 31.2-32 19.7-43.4-13.9-13.6-54.3-9.7-73.6-7.2zM377 105L279 7c-4.5-4.5-10.6-7-17-7h-6v128h128v-6.1c0-6.3-2.5-12.4-7-16.9zm-74.1 255.3c4.1-2.7-2.5-11.9-42.8-9 37.1 15.8 42.8 9 42.8 9z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Formulario de inscripci\u00f3n<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-caab5df e-con-full e-flex e-con e-child\" data-id=\"caab5df\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fc9656f elementor-widget elementor-widget-shortcode\" data-id=\"fc9656f\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p 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; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/es\/wp-json\/wp\/v2\/pages\/325#gf_6' data-formid='6' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/325#gf_6\"><input id=\"gw_page_progression\" name=\"gw_page_progression\" value=\"1\" type=\"hidden\" \/><input id=\"gpmpn_pages_visited_6\" name=\"gpmpn_pages_visited_6\" value=\"[1]\" type=\"hidden\" \/><input id=\"gpmpn_page_validity_6\" name=\"gpmpn_page_validity_6\" value=\"{&quot;1&quot;:false,&quot;2&quot;:false,&quot;3&quot;:false,&quot;4&quot;:false,&quot;5&quot;:false,&quot;6&quot;:false,&quot;7&quot;:false,&quot;8&quot;:false,&quot;9&quot;:false,&quot;10&quot;:false,&quot;11&quot;:false,&quot;12&quot;:false}\" type=\"hidden\" \/><div id='gf_page_steps_6' class='gf_page_steps'><div id='gf_step_6_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Formulario De Registro Del Paciente<\/span><\/div><div id='gf_step_6_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Formularios de historia m\u00e9dico<\/span><\/div><div id='gf_step_6_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Consentimiento para la medicaci\u00f3n<\/span><\/div><div id='gf_step_6_4' class='gf_step gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Historia familiar<\/span><\/div><div id='gf_step_6_5' class='gf_step gf_step_pending'><span class='gf_step_number'>5<\/span><span class='gf_step_label'>Mantenimiento Preventivo de Salud<\/span><\/div><div id='gf_step_6_6' class='gf_step gf_step_pending'><span class='gf_step_number'>6<\/span><span class='gf_step_label'>S\u00edntomas<\/span><\/div><div id='gf_step_6_7' class='gf_step gf_step_pending'><span class='gf_step_number'>7<\/span><span class='gf_step_label'>Cuestionario acerca de Depresi\u00f3n<\/span><\/div><div id='gf_step_6_8' class='gf_step gf_step_pending'><span class='gf_step_number'>8<\/span><span class='gf_step_label'>Directivas Anticipadas<\/span><\/div><div id='gf_step_6_9' class='gf_step gf_step_pending'><span class='gf_step_number'>9<\/span><span class='gf_step_label'>General Consent<\/span><\/div><div id='gf_step_6_10' class='gf_step gf_step_pending'><span class='gf_step_number'>10<\/span><span class='gf_step_label'>Divulgaci\u00f3n de la HIPAA<\/span><\/div><div id='gf_step_6_11' class='gf_step gf_step_pending'><span class='gf_step_number'>11<\/span><span class='gf_step_label'>Formulario de Divulgaci\u00f3n de Registros M\u00e9dicos<\/span><\/div><div id='gf_step_6_12' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>12<\/span><span class='gf_step_label'>Revisar\/presentar<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_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_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_449\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_449'>Nombre<\/label><div class='ginput_container'><input name='input_449' id='input_6_449' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_449'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_6_389\" 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_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_389'>N\u00famero de confirmaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_389' id='input_6_389' type='text' value='{entry_id}' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_326\" 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\"  ><h3 style=\"text-decoration: underline;\">Formulario De Registro Del Paciente<\/h3><\/div><div id=\"field_6_311\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><span style=\"color:#b72a2a;\"><b>*El asterisco indica un campo obligatorio.<\/b><\/span><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name 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 PACIENTE (APELLIDO -- PRIMER NOMBRE -- INICIAL SEGUNDO 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 has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_6_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_6_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_1_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_2\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'>Correo Electr\u00f3nico<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_6_2' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_27\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_27'>Tel\u00e9fono De Casa<\/label><div class='ginput_container ginput_container_phone'><input name='input_27' id='input_6_27' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Tel\u00e9fono M\u00f3vil<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_6_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tel\u00e9fono M\u00f3vil - \u00bfEs un iPhone?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_7'>\n\t\t\t<div class='gchoice gchoice_6_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='No'  id='choice_6_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_0' id='label_6_7_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yes'  id='choice_6_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_7_1' id='label_6_7_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_4\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcccion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_6_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_6_4_1' id='input_6_4_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_6_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_3' id='input_6_4_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_4_4_container' >\n                                        <select name='input_4.4' id='input_6_4_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_4_4' id='input_6_4_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_6_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_6_4_5' id='input_6_4_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_6_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_312\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_312'>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_312' id='input_6_312' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_312_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_312_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_312' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_8\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>N\u00famero de Seguro Social<\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_6_8' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Sexo<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_6_9'>\n\t\t\t<div class='gchoice gchoice_6_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male'  id='choice_6_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_9_0' id='label_6_9_0' class='gform-field-label gform-field-label--type-inline'>Masculino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female'  id='choice_6_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_9_1' id='label_6_9_1' class='gform-field-label gform-field-label--type-inline'>Femenino<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Estado civil<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_6_10'>\n\t\t\t<div class='gchoice gchoice_6_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Single'  id='choice_6_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_0' id='label_6_10_0' class='gform-field-label gform-field-label--type-inline'>Soltero<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Married'  id='choice_6_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_1' id='label_6_10_1' class='gform-field-label gform-field-label--type-inline'>Casado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_10_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='gf_other_choice'  id='choice_6_10_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_10_2' id='label_6_10_2' class='gform-field-label gform-field-label--type-inline'>Otros<\/label><br \/><input id='input_6_10_other' class='gchoice_other_control' name='input_10_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_22'>Nombre del empleador del paciente<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_15\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n del empleador del paciente<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_15' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_15_1_container' >\n                                        <input type='text' name='input_15.1' id='input_6_15_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_15_1' id='input_6_15_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_15_3_container' >\n                                    <input type='text' name='input_15.3' id='input_6_15_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_15_3' id='input_6_15_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_15_4_container' >\n                                        <select name='input_15.4' id='input_6_15_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_15_4' id='input_6_15_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_15_5_container' >\n                                    <input type='text' name='input_15.5' id='input_6_15_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_15_5' id='input_6_15_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_6_15_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_16\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_16'>Tel\u00e9fono del empleador<\/label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_6_16' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_64\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Informacion Del Asegurado O Responsable<\/h3><\/div><fieldset id=\"field_6_18\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Informacion Del Asegurado O Responsable Nombre<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_6_18'>\n                            \n                            <span id='input_6_18_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.3' id='input_6_18_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            <span id='input_6_18_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.4' id='input_6_18_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_4' class='gform-field-label gform-field-label--type-sub'>Middle<\/label>\n                                                <\/span>\n                            <span id='input_6_18_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.6' id='input_6_18_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_18_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_314\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_314'>Relaci\u00f3n con el paciente<\/label><div class='ginput_container ginput_container_select'><select name='input_314' id='input_6_314' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Spouse' >C\u00f3nyuge<\/option><option value='Parent' >Padre<\/option><option value='Guardian' >Guardi\u00e1n<\/option><option value='Self' >Auto<\/option><\/select><\/div><\/div><fieldset id=\"field_6_25\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n (si es diferente del paciente)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_25' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_25_1_container' >\n                                        <input type='text' name='input_25.1' id='input_6_25_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_25_1' id='input_6_25_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_25_3_container' >\n                                    <input type='text' name='input_25.3' id='input_6_25_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_25_3' id='input_6_25_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_25_4_container' >\n                                        <select name='input_25.4' id='input_6_25_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_25_4' id='input_6_25_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_25_5_container' >\n                                    <input type='text' name='input_25.5' id='input_6_25_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_25_5' id='input_6_25_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_25.6' id='input_6_25_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_3\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_3'>Informacion Del Asegurado O Responsable Tel\u00e9fono De Casa<\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_6_3' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_28\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_28'>Informacion Del Asegurado O Responsable Tel\u00e9fono Del Trabajo<\/label><div class='ginput_container ginput_container_phone'><input name='input_28' id='input_6_28' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_21\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_21'>Informacion Del Asegurado O Responsable Seguro Social<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_20\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_20'>Informacion Del Asegurado O Responsable Fecha Nacimiento<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Informacion Del Asegurado O Responsable Empleador<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_6_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Informacion Del Seguro Medico<\/h3><\/div><div id=\"field_6_26\" class=\"gfield gfield--type-text gfield--input-type-text 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_6_26'>Nombre Del Seguro Primario<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_6_26' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_32\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direccion (al respaldo de la tarjeta del seguro m\u00e9dico)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_32_1_container' >\n                                        <input type='text' name='input_32.1' id='input_6_32_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_32_1' id='input_6_32_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_32_3_container' >\n                                    <input type='text' name='input_32.3' id='input_6_32_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_32_3' id='input_6_32_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_32_4_container' >\n                                        <select name='input_32.4' id='input_6_32_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_32_4' id='input_6_32_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_32_5_container' >\n                                    <input type='text' name='input_32.5' id='input_6_32_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_32_5' id='input_6_32_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_6_32_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_41'>N\u00famero de grupo<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_6_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_42\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_42'>N\u00famero de identificaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_6_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tipo de Seguro Primario<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_43'>\n\t\t\t<div class='gchoice gchoice_6_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='HMO'  id='choice_6_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_0' id='label_6_43_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='PPO'  id='choice_6_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_43_1' id='label_6_43_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_44\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_44'>Telefono Compania De Seguro<\/label><div class='ginput_container ginput_container_phone'><input name='input_44' id='input_6_44' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><div id=\"field_6_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_31'>Nombre del seguro secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_6_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_19\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direccion (al respaldo de la tarjeta del seguro m\u00e9dico secundario)<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_6_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_19_1' id='input_6_19_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_6_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_19_3' id='input_6_19_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_19_4_container' >\n                                        <select name='input_19.4' id='input_6_19_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_19_4' id='input_6_19_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_6_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_19_5' id='input_6_19_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_6_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_34\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_34'>Numero De Grupo Secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_6_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_35\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_35'>Numero De Identificacion Secundario<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_6_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Tipo de seguro secundario<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_36'>\n\t\t\t<div class='gchoice gchoice_6_36_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='HMO'  id='choice_6_36_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_0' id='label_6_36_0' class='gform-field-label gform-field-label--type-inline'>HMO<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_36_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_36' type='radio' value='PPO'  id='choice_6_36_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_36_1' id='label_6_36_1' class='gform-field-label gform-field-label--type-inline'>PPO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_37\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_37'>Telefono Compania De Seguro Secundario<\/label><div class='ginput_container ginput_container_phone'><input name='input_37' id='input_6_37' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_30\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Informaci\u00f3n De Admisi\u00f3n<\/h3><\/div><div id=\"field_6_45\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_45'>Medico De Atencion Primaria<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_6_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>Nombre Del Medico Que Lo Remitio<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_47\" class=\"gfield gfield--type-name gfield--input-type-name 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' >Contacto En Caso De Emergencia<\/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_6_47'>\n                            \n                            <span id='input_6_47_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.3' id='input_6_47_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_47_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_47_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_47.6' id='input_6_47_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_6_47_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_48'>Contacto En Caso De Emergencia Relacion<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_6_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_49\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>Contacto En Caso De Emergencia Numero Telefonico<\/label><div class='ginput_container ginput_container_phone'><input name='input_49' id='input_6_49' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfActualmente se encuentra hospitalizado o est\u00e1 inscrito en un hospicio o centro de enfermer\u00eda especializada?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_52'>\n\t\t\t<div class='gchoice gchoice_6_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Yes'  id='choice_6_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_52_0' id='label_6_52_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_6_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_52_1' id='label_6_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_53'>Nombre del establecimiento<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_6_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_57\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_57'>Tel\u00e9fono del centro<\/label><div class='ginput_container ginput_container_phone'><input name='input_57' id='input_6_57' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_58\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n del establecimiento<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_58' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_58_1_container' >\n                                        <input type='text' name='input_58.1' id='input_6_58_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_58_1' id='input_6_58_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_58_3_container' >\n                                    <input type='text' name='input_58.3' id='input_6_58_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_58_3' id='input_6_58_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_58_4_container' >\n                                        <select name='input_58.4' id='input_6_58_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_58_4' id='input_6_58_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_58_5_container' >\n                                    <input type='text' name='input_58.5' id='input_6_58_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_58_5' id='input_6_58_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_58.6' id='input_6_58_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_59\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><fieldset id=\"field_6_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfRecibe beneficios de la Administraci\u00f3n de Veteranos?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_55'>\n\t\t\t<div class='gchoice gchoice_6_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_6_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_55_0' id='label_6_55_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_6_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_55_1' id='label_6_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_56\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_56'>Nombre de VA<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_6_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_54\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_54'>Tel\u00e9fono VA<\/label><div class='ginput_container ginput_container_phone'><input name='input_54' id='input_6_54' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_51\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n de VA<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_51' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_51_1_container' >\n                                        <input type='text' name='input_51.1' id='input_6_51_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_51_1' id='input_6_51_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_51_3_container' >\n                                    <input type='text' name='input_51.3' id='input_6_51_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_51_3' id='input_6_51_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_51_4_container' >\n                                        <select name='input_51.4' id='input_6_51_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_51_4' id='input_6_51_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_51_5_container' >\n                                    <input type='text' name='input_51.5' id='input_6_51_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_51_5' id='input_6_51_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_51.6' id='input_6_51_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h1><\/hr><\/h1><\/div><fieldset id=\"field_6_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCu\u00e1l de las siguientes opciones describe su raza?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_60'>\n\t\t\t<div class='gchoice gchoice_6_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Asian'  id='choice_6_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_0' id='label_6_60_0' class='gform-field-label gform-field-label--type-inline'>Asi\u00e1tico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Caucasian'  id='choice_6_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_1' id='label_6_60_1' class='gform-field-label gform-field-label--type-inline'>Blanco<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Black \/ African American'  id='choice_6_60_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_2' id='label_6_60_2' class='gform-field-label gform-field-label--type-inline'>Negro \/ afroamericano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Hispanic'  id='choice_6_60_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_3' id='label_6_60_3' class='gform-field-label gform-field-label--type-inline'>Hispano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Subcontinent Asian American'  id='choice_6_60_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_4' id='label_6_60_4' class='gform-field-label gform-field-label--type-inline'>Subcontinente Asi\u00e1tico Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Asian Pacific American'  id='choice_6_60_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_5' id='label_6_60_5' class='gform-field-label gform-field-label--type-inline'>Asi\u00e1tico Pacifico Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Native American'  id='choice_6_60_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_6' id='label_6_60_6' class='gform-field-label gform-field-label--type-inline'>Nativo Americano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='American Indian \/ Alaskan Native'  id='choice_6_60_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_7' id='label_6_60_7' class='gform-field-label gform-field-label--type-inline'>Indio Americano \/ Nativo de Alaska<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Hawaiian'  id='choice_6_60_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_8' id='label_6_60_8' class='gform-field-label gform-field-label--type-inline'>Hawaiano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Pacific Islander'  id='choice_6_60_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_9' id='label_6_60_9' class='gform-field-label gform-field-label--type-inline'>Isle\u00f1o del Pac\u00edfico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='More than one race'  id='choice_6_60_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_10' id='label_6_60_10' class='gform-field-label gform-field-label--type-inline'>M\u00e1s de una Raza<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Other'  id='choice_6_60_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_11' id='label_6_60_11' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_60_12'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Decline'  id='choice_6_60_12' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_60_12' id='label_6_60_12' class='gform-field-label gform-field-label--type-inline'>Declino a Informar<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Favor indique un grupo \u00e9tnico que mejor describa su raza:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_61'>\n\t\t\t<div class='gchoice gchoice_6_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Hispanic or Latino'  id='choice_6_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_0' id='label_6_61_0' class='gform-field-label gform-field-label--type-inline'>Hispano o latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Non-Hispanic or Latino'  id='choice_6_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_1' id='label_6_61_1' class='gform-field-label gform-field-label--type-inline'>No hispano o latino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Decline'  id='choice_6_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_2' id='label_6_61_2' class='gform-field-label gform-field-label--type-inline'>Declino a Informar<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_61_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Don\u2019t know'  id='choice_6_61_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_61_3' id='label_6_61_3' class='gform-field-label gform-field-label--type-inline'>No s\u00e9<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEn qu\u00e9 idioma se siente m\u00e1s c\u00f3modo al hablar sobre su atenci\u00f3n m\u00e9dica?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_62'>\n\t\t\t<div class='gchoice gchoice_6_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='English'  id='choice_6_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_0' id='label_6_62_0' class='gform-field-label gform-field-label--type-inline'>Ingl\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Spanish'  id='choice_6_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_1' id='label_6_62_1' class='gform-field-label gform-field-label--type-inline'>Espa\u00f1ol<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='German'  id='choice_6_62_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_2' id='label_6_62_2' class='gform-field-label gform-field-label--type-inline'>Alem\u00e1n<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='French'  id='choice_6_62_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_3' id='label_6_62_3' class='gform-field-label gform-field-label--type-inline'>Franc\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Italian'  id='choice_6_62_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_4' id='label_6_62_4' class='gform-field-label gform-field-label--type-inline'>Italiano<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Russian'  id='choice_6_62_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_5' id='label_6_62_5' class='gform-field-label gform-field-label--type-inline'>Ruso<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Portuguese'  id='choice_6_62_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_6' id='label_6_62_6' class='gform-field-label gform-field-label--type-inline'>Portugu\u00e9s<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Chinese'  id='choice_6_62_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_7' id='label_6_62_7' class='gform-field-label gform-field-label--type-inline'>Chino<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Other'  id='choice_6_62_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_8' id='label_6_62_8' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Decline'  id='choice_6_62_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_9' id='label_6_62_9' class='gform-field-label gform-field-label--type-inline'>Declino a Informar<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_62_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Don\u2019t know'  id='choice_6_62_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_62_10' id='label_6_62_10' class='gform-field-label gform-field-label--type-inline'>No s\u00e9<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfCon qu\u00e9 frecuencia usa internet para recopilar informaci\u00f3n?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_63'>\n\t\t\t<div class='gchoice gchoice_6_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Always'  id='choice_6_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_0' id='label_6_63_0' class='gform-field-label gform-field-label--type-inline'>Siempre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Usually'  id='choice_6_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_1' id='label_6_63_1' class='gform-field-label gform-field-label--type-inline'>Generalmente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Sometimes'  id='choice_6_63_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_2' id='label_6_63_2' class='gform-field-label gform-field-label--type-inline'>Algunas Veces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_63_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Never'  id='choice_6_63_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_63_3' id='label_6_63_3' class='gform-field-label gform-field-label--type-inline'>Nunca<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_88' 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_6_2' class='gform_page' data-js='page-field-id-88' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_89\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Formularios de historia m\u00e9dico<\/h3><\/div><div id=\"field_6_66\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_66'>Diagn\u00f3stico de c\u00e1ncer o motivo de consulta:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_66' id='input_6_66' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Historial m\u00e9dico<\/h3><\/div><fieldset id=\"field_6_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_3col 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' >Marque todo lo que corresponda:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_68'><div class='gchoice gchoice_6_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Allergies'  id='choice_6_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_1' id='label_6_68_1' class='gform-field-label gform-field-label--type-inline'>Alergias<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='COPD'  id='choice_6_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_2' id='label_6_68_2' class='gform-field-label gform-field-label--type-inline'>Enfermedad pulmonar obstructiva cr\u00f3nica (EPOC)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.3' type='checkbox'  value='High blood pressure'  id='choice_6_68_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_3' id='label_6_68_3' class='gform-field-label gform-field-label--type-inline'>Alta presi\u00f3n \/ Hipertensi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.4' type='checkbox'  value='Anxiety'  id='choice_6_68_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_4' id='label_6_68_4' class='gform-field-label gform-field-label--type-inline'>Ansiedad<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.5' type='checkbox'  value='Depression'  id='choice_6_68_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_5' id='label_6_68_5' class='gform-field-label gform-field-label--type-inline'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.6' type='checkbox'  value='Inflammatory Bowel Disease (Crohn\u2019s disease, colitis, etc)'  id='choice_6_68_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_6' id='label_6_68_6' class='gform-field-label gform-field-label--type-inline'>Enfermedad inflamatoria intestinal (enfermedad de Crohn, colitis, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.7' type='checkbox'  value='Anemia\/Blood Disorder'  id='choice_6_68_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_7' id='label_6_68_7' class='gform-field-label gform-field-label--type-inline'>Anemia\/problemas sangu\u00edneos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.8' type='checkbox'  value='Diabetes'  id='choice_6_68_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_8' id='label_6_68_8' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.9' type='checkbox'  value='Migraines\/headaches'  id='choice_6_68_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_9' id='label_6_68_9' class='gform-field-label gform-field-label--type-inline'>Migra\u00f1as\/dolores de cabeza<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.11' type='checkbox'  value='Arthritis'  id='choice_6_68_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_11' id='label_6_68_11' class='gform-field-label gform-field-label--type-inline'>Artritis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.12' type='checkbox'  value='Diverticulitis'  id='choice_6_68_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_12' id='label_6_68_12' class='gform-field-label gform-field-label--type-inline'>Diverticulitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.13' type='checkbox'  value='Neuropathy'  id='choice_6_68_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_13' id='label_6_68_13' class='gform-field-label gform-field-label--type-inline'>Neuropat\u00eda<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.14' type='checkbox'  value='Asthma'  id='choice_6_68_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_14' id='label_6_68_14' class='gform-field-label gform-field-label--type-inline'>Asma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.15' type='checkbox'  value='Erectile dysfunction'  id='choice_6_68_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_15' id='label_6_68_15' class='gform-field-label gform-field-label--type-inline'>Disfunci\u00f3n er\u00e9ctil<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.16' type='checkbox'  value='Psychosis'  id='choice_6_68_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_16' id='label_6_68_16' class='gform-field-label gform-field-label--type-inline'>Psicosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.17' type='checkbox'  value='Atrial fibrillation\/irregular heartbeat'  id='choice_6_68_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_17' id='label_6_68_17' class='gform-field-label gform-field-label--type-inline'>Fibrilaci\u00f3n auricular \/ latidos irregulares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.18' type='checkbox'  value='Fibromyalgia'  id='choice_6_68_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_18' id='label_6_68_18' class='gform-field-label gform-field-label--type-inline'>Fibromialgia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.19' type='checkbox'  value='Rheumatoid Arthritis'  id='choice_6_68_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_19' id='label_6_68_19' class='gform-field-label gform-field-label--type-inline'>Artritis reumatoide<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.21' type='checkbox'  value='Autoimmune disorder (lupus, scleroderma, RA, etc)'  id='choice_6_68_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_21' id='label_6_68_21' class='gform-field-label gform-field-label--type-inline'>Trastorno autoinmune (lupus, esclerodermia, AR, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.22' type='checkbox'  value='GERD'  id='choice_6_68_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_22' id='label_6_68_22' class='gform-field-label gform-field-label--type-inline'>Reflujo gastroesof\u00e1gico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.23' type='checkbox'  value='Seizures'  id='choice_6_68_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_23' id='label_6_68_23' class='gform-field-label gform-field-label--type-inline'>Convulsiones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.24' type='checkbox'  value='Bipolar Disorder'  id='choice_6_68_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_24' id='label_6_68_24' class='gform-field-label gform-field-label--type-inline'>Trastorno bipolar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.25' type='checkbox'  value='Gout'  id='choice_6_68_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_25' id='label_6_68_25' class='gform-field-label gform-field-label--type-inline'>Gota<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.26' type='checkbox'  value='Stroke'  id='choice_6_68_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_26' id='label_6_68_26' class='gform-field-label gform-field-label--type-inline'>Derrame Cerebral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.27' type='checkbox'  value='Blood clots or pulmonary embolism'  id='choice_6_68_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_27' id='label_6_68_27' class='gform-field-label gform-field-label--type-inline'>Co\u00e1gulos de sangre o embolia pulmonar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.28' type='checkbox'  value='Heart Attack'  id='choice_6_68_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_28' id='label_6_68_28' class='gform-field-label gform-field-label--type-inline'>Ataque de coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.29' type='checkbox'  value='Thyroid Disorder'  id='choice_6_68_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_29' id='label_6_68_29' class='gform-field-label gform-field-label--type-inline'>Trastorno de la tiroides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.31' type='checkbox'  value='BPH (prostate)'  id='choice_6_68_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_31' id='label_6_68_31' class='gform-field-label gform-field-label--type-inline'>Hiperplasia prost\u00e1tica benigna<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.32' type='checkbox'  value='Heart Disease'  id='choice_6_68_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_32' id='label_6_68_32' class='gform-field-label gform-field-label--type-inline'>Enfermedades Cardiacas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.33' type='checkbox'  value='Tremors'  id='choice_6_68_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_33' id='label_6_68_33' class='gform-field-label gform-field-label--type-inline'>Temblores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.34' type='checkbox'  value='CAD (coronary artery disease)'  id='choice_6_68_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_34' id='label_6_68_34' class='gform-field-label gform-field-label--type-inline'>Arteriopat\u00eda coronaria (CAD)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.35' type='checkbox'  value='High cholesterol'  id='choice_6_68_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_35' id='label_6_68_35' class='gform-field-label gform-field-label--type-inline'>Colesterol alto<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_68_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.36' type='checkbox'  value='Osteoporosis'  id='choice_6_68_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_68_36' id='label_6_68_36' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_71\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_71'>C\u00e1ncer, historia previa:<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_6_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_72\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_72'>\u00bfEnfermedad infecciosa (HIV, hepatitis, tuberculosis, etc.)?<\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_6_72' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_73\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_73'>Otros<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_6_73' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha recibido radioterapia?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_83'>\n\t\t\t<div class='gchoice gchoice_6_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='Yes'  id='choice_6_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_0' id='label_6_83_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_6_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_83_1' id='label_6_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_84\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_84'>En caso afirmativo, \u00bfcu\u00e1ndo?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_84' id='input_6_84' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_84_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_84_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_84' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_77\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_77'>Nombre del m\u00e9dico de radioterapia\/centro de salud<\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_6_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_86\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_86'>Direcci\u00f3n del centro de radioterapia<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_6_86' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_366\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_366'>\u00bfQu\u00e9 \u00e1rea fue tratada?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_366' id='input_6_366' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha recibido quimioterapia?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_74'>\n\t\t\t<div class='gchoice gchoice_6_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_6_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_0' id='label_6_74_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_6_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_74_1' id='label_6_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_76'>En caso afirmativo, \u00bfcu\u00e1ndo?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_6_76' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_76_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_76' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_87\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_87'>Nombre del m\u00e9dico de quimioterapia\/centro de salud<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_6_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_80\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_80'>Direcci\u00f3n de quimioterapia<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_6_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_17\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Cirug\u00edas Pasadas<\/h3><\/div><fieldset id=\"field_6_107\" class=\"gfield gfield--type-list gfield--input-type-list 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' >Indique la cirug\u00eda, el a\u00f1o de la operaci\u00f3n, el cirujano y la ubicaci\u00f3n (si se conoce). Haga clic en el s\u00edmbolo \"M\u00c1S\" para agregar m\u00e1s filas.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Procedimiento\/operaci\u00f3n<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Fecha<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">M\u00e9dico<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Lugar<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell1 gform-grid-col' data-label='Procedure\/Operation'><input aria-invalid='false'   aria-label='Procedimiento\/operaci\u00f3n, fila 1' data-aria-label-template='Procedure\/Operation, Row {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell2 gform-grid-col' data-label='Date'><input aria-invalid='false'   aria-label='Fecha, Fila 1' data-aria-label-template='Date, Row {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell3 gform-grid-col' data-label='Physician'><input aria-invalid='false'   aria-label='M\u00e9dico, Fila 1' data-aria-label-template='Physician, Row {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_107_cell4 gform-grid-col' data-label='Location'><input aria-invalid='false'   aria-label='Ubicaci\u00f3n, Fila 1' data-aria-label-template='Location, Row {0}' type='text' name='input_107[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 4)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 4)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene alg\u00fan dispositivo m\u00e9dico implantado, como un PACEMAKER, un DEFIBRILADOR, un neuroestimulador, bombas de infusi\u00f3n de drogas, etc.?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_96'>\n\t\t\t<div class='gchoice gchoice_6_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_6_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_96_0' id='label_6_96_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_6_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_96_1' id='label_6_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_97\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong><em>En caso afirmativo, proporcione una copia de su tarjeta de dispositivo m\u00e9dico a la recepci\u00f3n.<\/strong><\/em><\/p><\/div><div id=\"field_6_98\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Alergias<\/h3><\/div><fieldset id=\"field_6_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >\u00bfEs al\u00e9rgico a alg\u00fan medicamento?<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_6_99'>\n\t\t\t<div class='gchoice gchoice_6_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_6_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_99_0' id='label_6_99_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_6_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_99_1' id='label_6_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_100\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_100'>En caso afirmativo, nombre del medicamento\/reacci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_6_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >\u00bfEs al\u00e9rgico al l\u00e1tex?<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_6_104'>\n\t\t\t<div class='gchoice gchoice_6_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_6_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_104_0' id='label_6_104_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_6_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_104_1' id='label_6_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_105\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_105'>Si es as\u00ed, reacci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_6_105' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_103\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >\u00bfEs al\u00e9rgico al contraste IV?<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_6_103'>\n\t\t\t<div class='gchoice gchoice_6_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_6_103_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_103_0' id='label_6_103_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_6_103_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_103_1' id='label_6_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_102\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_102'>Si es as\u00ed, reacci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_6_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_106\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_106'>Otros (comida, cinta, ambiental, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_106' id='input_6_106' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_108\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration:underline;\">Medicamentos<\/h3><\/div><div id=\"field_6_109\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_109'>Nombre de la farmacia<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_6_109' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_110\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_110'>N\u00famero de la farmacia<\/label><div class='ginput_container ginput_container_phone'><input name='input_110' id='input_6_110' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_111\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n de la farmacia<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_6_111' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_111_1_container' >\n                                        <input type='text' name='input_111.1' id='input_6_111_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_111_1' id='input_6_111_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_111.4' id='input_6_111_4' value=''\/><input type='hidden' class='gform_hidden' name='input_111.6' id='input_6_111_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_6_90\" class=\"gfield gfield--type-list gfield--input-type-list 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' >Enumere TODOS los medicamentos. Haga clic en el s\u00edmbolo \"M\u00c1S\" para agregar m\u00e1s filas.<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Medicaci\u00f3n<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Dosis<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Frecuencia<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">M\u00e9dico que prescribe<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell1 gform-grid-col' data-label='Medication'><input aria-invalid='false'   aria-label='Medicaci\u00f3n, Fila 1' data-aria-label-template='Medication, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell2 gform-grid-col' data-label='Dose'><input aria-invalid='false'   aria-label='Dosis, Fila 1' data-aria-label-template='Dose, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell3 gform-grid-col' data-label='Frequency'><input aria-invalid='false'   aria-label='Frecuencia, Fila 1' data-aria-label-template='Frequency, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_90_cell4 gform-grid-col' data-label='Prescribing Physician'><input aria-invalid='false'   aria-label='M\u00e9dico prescriptor, fila 1' data-aria-label-template='Prescribing Physician, Row {0}' type='text' name='input_90[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>A\u00f1adir<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Eliminar<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_121' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_121' 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_6_3' class='gform_page' data-js='page-field-id-121' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_371\" 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\"  ><h3 style=\"padding-top: 50px;\">Consentimiento para obtener el historial de medicamentos del paciente<\/h3>\n<p>El historial de medicamentos del paciente es una lista de prescripciones que le han recetado los proveedores de atenci\u00f3n m\u00e9dica. Una variedad de fuentes, incluidas farmacias y aseguradoras de salud, contribuyen a la recopilaci\u00f3n de este historial. <\/p>\n<p>La informaci\u00f3n recopilada se almacena en el sistema de registro m\u00e9dico electr\u00f3nico de la cl\u00ednica y se convierte en parte de su registro m\u00e9dico personal. El historial de medicamentos es muy importante para ayudar a los doctores yasistentes m\u00e9dicos a tratar sus s\u00edntomas y \/ o enfermedad de manera adecuada y evitar interacciones de medicamentos potencialmente peligrosos. <\/p>\n<p>Es muy importante que usted y su doctor discutan todos sus edicamentos para asegurarse de que su historial de medicamento registrado sea 100% exacto. Algunas farmacias no ofrecen informaci\u00f3n sobre el historial de prescripciones, y es posible que su historial de medicamentos no incluya los medicamentos comprados sin usar su seguro m\u00e9dico.<\/p>\n<p>Adem\u00e1s, es posible que no se incluyan los medicamentos de venta libre, los suplementos o los remedios herbales que usted toma por su cuenta.<p><\/div><fieldset id=\"field_6_373\" 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 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_373.1' id='input_6_373_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_6_373_1' >Doy mi permiso para permitir que mi doctor y asistentes m\u00e9dicos obtenga mi historial de medicamentos de mi farmacia, mis planes de salud y mis otros proveedores de atenci\u00f3n m\u00e9dica. Valido por 1 a\u00f1o desde la fecha de la firma <strong>V\u00e1lido durante 1 a\u00f1o a partir de la fecha de la firma.<\/strong><\/label><input type='hidden' name='input_373.2' value='I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers. &lt;strong&gt;Valid for 1 year from date of signature.&lt;\/strong&gt;' class='gform_hidden' \/><input type='hidden' name='input_373.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_374\" class=\"gfield gfield--type-text gfield--input-type-text 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_6_374'>Nombre del paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_374' id='input_6_374' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_375\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon 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_6_375'>Fecha:<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_375' id='input_6_375' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_375_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_375_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_375' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_370' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_370' 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_6_4' class='gform_page' data-js='page-field-id-370' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration:underline;\">Historia familiar<\/h3><\/div><div id=\"field_6_118\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_118'>Padre: si vive, edad<\/label><div class='ginput_container ginput_container_number'><input name='input_118' id='input_6_118' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_119\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_119'>Padre: si falleci\u00f3, edad de fallecimiento<\/label><div class='ginput_container ginput_container_number'><input name='input_119' id='input_6_119' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_120\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_120'>Problemas m\u00e9dicos del padre<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_120' id='input_6_120' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_122\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_122'>Madre: si vive, edad<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_6_122' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_116\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_116'>Madre: si falleci\u00f3, edad de fallecimiento<\/label><div class='ginput_container ginput_container_number'><input name='input_116' id='input_6_116' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_124\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_124'>Problemas m\u00e9dicos de la madre<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_124' id='input_6_124' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_125\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_125'>Hermanos: # de hermanas<\/label><div class='ginput_container ginput_container_number'><input name='input_125' id='input_6_125' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_126\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_126'>Hermanos: # de hermanos<\/label><div class='ginput_container ginput_container_number'><input name='input_126' id='input_6_126' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_127\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_127'>Hermanos: Problemas m\u00e9dicos\/fallecidos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_127' id='input_6_127' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_115\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_115'>Hijos: # de Hijas<\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_6_115' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_123\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_123'>Hijos: # de Hijos<\/label><div class='ginput_container ginput_container_number'><input name='input_123' id='input_6_123' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_117\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_117'>Ni\u00f1os: Problemas m\u00e9dicos\/fallecidos<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_117' id='input_6_117' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_165\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:50px; text-decoration: underline;\">Historial social<\/h3><\/div><fieldset id=\"field_6_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Estado civil:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_129'>\n\t\t\t<div class='gchoice gchoice_6_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Single'  id='choice_6_129_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_0' id='label_6_129_0' class='gform-field-label gform-field-label--type-inline'>Soltero<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Married'  id='choice_6_129_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_1' id='label_6_129_1' class='gform-field-label gform-field-label--type-inline'>Casado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Divorced'  id='choice_6_129_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_2' id='label_6_129_2' class='gform-field-label gform-field-label--type-inline'>Divorciado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Widowed'  id='choice_6_129_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_3' id='label_6_129_3' class='gform-field-label gform-field-label--type-inline'>Viudo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_129_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Separated'  id='choice_6_129_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_129_4' id='label_6_129_4' class='gform-field-label gform-field-label--type-inline'>Separado<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_130\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_130'>Nombre del c\u00f3nyuge u otra persona significativa:<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_6_130' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_137\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Historia Socio-Geogr\u00e1fica<\/h3><\/div><div id=\"field_6_132\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_132'>\u00bfD\u00f3nde naci\u00f3?<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_6_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_133\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_133'>\u00bfD\u00f3nde ha vivido la mayor parte de su vida?<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_6_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_136\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfVives en este estado todo el a\u00f1o?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_136'>\n\t\t\t<div class='gchoice gchoice_6_136_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='Yes'  id='choice_6_136_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_136_0' id='label_6_136_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_136_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_136' type='radio' value='No'  id='choice_6_136_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_136_1' id='label_6_136_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_135\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Indique su direcci\u00f3n alternativa:<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_135' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_135_1_container' >\n                                        <input type='text' name='input_135.1' id='input_6_135_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_135_1' id='input_6_135_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_135_3_container' >\n                                    <input type='text' name='input_135.3' id='input_6_135_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_135_3' id='input_6_135_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_135_4_container' >\n                                        <select name='input_135.4' id='input_6_135_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_6_135_4' id='input_6_135_4_label' class='gform-field-label gform-field-label--type-sub'>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_135_5_container' >\n                                    <input type='text' name='input_135.5' id='input_6_135_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_135_5' id='input_6_135_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_135.6' id='input_6_135_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_131\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Ocupaci\u00f3n\/Historial de servicio<\/h3><\/div><div id=\"field_6_138\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_138'>Ocupaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_6_138' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Eres t\u00fa:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_141'>\n\t\t\t<div class='gchoice gchoice_6_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Retired'  id='choice_6_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_141_0' id='label_6_141_0' class='gform-field-label gform-field-label--type-inline'>Retirado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Disabled'  id='choice_6_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_141_1' id='label_6_141_1' class='gform-field-label gform-field-label--type-inline'>Discapacitados<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_139\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_139'>\u00bfRaz\u00f3n de la discapacidad?<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_6_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_140\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHa estado en el ejercito?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_140'>\n\t\t\t<div class='gchoice gchoice_6_140_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='No'  id='choice_6_140_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_140_0' id='label_6_140_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_140_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_140' type='radio' value='Yes'  id='choice_6_140_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_140_1' id='label_6_140_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_145\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Que usted sepa, \u00bfalguna vez trabaj\u00f3 en una ocupaci\u00f3n que implicara la exposici\u00f3n al asbesto u otras sustancias qu\u00edmicas cancerosas, humos o carcin\u00f3genos?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_145'>\n\t\t\t<div class='gchoice gchoice_6_145_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='No'  id='choice_6_145_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_145_0' id='label_6_145_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_145_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_145' type='radio' value='Yes'  id='choice_6_145_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_145_1' id='label_6_145_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_143\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_143'>En caso afirmativo, describa:<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_6_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_144\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Historial de Sustancias<\/h3><\/div><fieldset id=\"field_6_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha fumado?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_154'>\n\t\t\t<div class='gchoice gchoice_6_154_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='No'  id='choice_6_154_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_154_0' id='label_6_154_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_154_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_154' type='radio' value='Yes'  id='choice_6_154_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_154_1' id='label_6_154_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_150\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >En caso afirmativo, \u00bfqu\u00e9?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_150'><div class='gchoice gchoice_6_150_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.1' type='checkbox'  value='Cigarettes'  id='choice_6_150_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_1' id='label_6_150_1' class='gform-field-label gform-field-label--type-inline'>Cigarrillos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_150_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.2' type='checkbox'  value='Cigars'  id='choice_6_150_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_2' id='label_6_150_2' class='gform-field-label gform-field-label--type-inline'>Puros<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_150_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_150.3' type='checkbox'  value='Pipe'  id='choice_6_150_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_150_3' id='label_6_150_3' class='gform-field-label gform-field-label--type-inline'>Tuber\u00eda<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_153\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_153'>\u00bfCu\u00e1ntos a\u00f1os fumando?<\/label><div class='ginput_container ginput_container_number'><input name='input_153' id='input_6_153' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_6_153\" \/><div class='gfield_description instruction' id='gfield_instruction_6_153'>Please enter a number from <strong>1<\/strong> to <strong>99<\/strong>.<\/div><\/div><\/div><div id=\"field_6_155\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_155'>\u00bfPaquetes\/n\u00famero por d\u00eda?<\/label><div class='ginput_container ginput_container_number'><input name='input_155' id='input_6_155' type='number' step='any' min='1' max='99' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_6_155\" \/><div class='gfield_description instruction' id='gfield_instruction_6_155'>Please enter a number from <strong>1<\/strong> to <strong>99<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_6_142\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Si es as\u00ed, lo ha dejado?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_142'>\n\t\t\t<div class='gchoice gchoice_6_142_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='No'  id='choice_6_142_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_142_0' id='label_6_142_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_142_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_142' type='radio' value='Yes'  id='choice_6_142_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_142_1' id='label_6_142_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_159\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_159'>En caso afirmativo, \u00bfcu\u00e1ndo dej\u00f3 de fumar?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_159' id='input_6_159' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_159_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_159_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_159' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha masticado tabaco?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_146'>\n\t\t\t<div class='gchoice gchoice_6_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_6_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_146_0' id='label_6_146_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_6_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_146_1' id='label_6_146_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_160\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_160'>\u00bfCu\u00e1nto?<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_6_160' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_161\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Si es as\u00ed, lo ha dejado?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_161'>\n\t\t\t<div class='gchoice gchoice_6_161_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='No'  id='choice_6_161_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_161_0' id='label_6_161_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_161_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_161' type='radio' value='Yes'  id='choice_6_161_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_161_1' id='label_6_161_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_162\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_162'>En caso afirmativo, \u00bfcu\u00e1ndo dej\u00f3 de mascar tabaco?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_162' id='input_6_162' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_162_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_162_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_162' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfToma bebidas alcoh\u00f3licas?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_147'>\n\t\t\t<div class='gchoice gchoice_6_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='No'  id='choice_6_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_147_0' id='label_6_147_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='Yes'  id='choice_6_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_147_1' id='label_6_147_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_157\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_157'>En caso afirmativo, \u00bfcon qu\u00e9 frecuencia y en qu\u00e9 cantidad bebe?<\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_6_157' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >En caso afirmativo, \u00bfHa dejado de beber?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_158'>\n\t\t\t<div class='gchoice gchoice_6_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_6_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_158_0' id='label_6_158_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_6_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_158_1' id='label_6_158_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_156\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_156'>En caso afirmativo, \u00bfcu\u00e1ndo dej\u00f3 de beber alcohol?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_156' id='input_6_156' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_156_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_156_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_156' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHa usado o usa drogas ilegales?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_148'>\n\t\t\t<div class='gchoice gchoice_6_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='No'  id='choice_6_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_148_0' id='label_6_148_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Yes'  id='choice_6_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_148_1' id='label_6_148_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_163\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_163'>En caso afirmativo, describa:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_163' id='input_6_163' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_50' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_50' 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_6_5' class='gform_page' data-js='page-field-id-50' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_178\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Mantenimiento Preventivo de Salud<\/h3><\/div><div id=\"field_6_351\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_351'>(Mujer) \u00daltima mamograf\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_351' id='input_6_351' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_352\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_352'>(Mujer) \u00daltima prueba de Papanicolaou:<\/label><div class='ginput_container ginput_container_text'><input name='input_352' id='input_6_352' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_353\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_353'>(Mujer) \u00daltima colonoscopia:<\/label><div class='ginput_container ginput_container_text'><input name='input_353' id='input_6_353' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_354\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_354'>(Female) Last bone density scan:<\/label><div class='ginput_container ginput_container_text'><input name='input_354' id='input_6_354' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_355\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_355'>(Mujer) \u00daltima vacuna contra la neumon\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_355' id='input_6_355' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_356\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_356'>(Mujer) \u00daltima vacuna contra la gripe:<\/label><div class='ginput_container ginput_container_text'><input name='input_356' id='input_6_356' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_357\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_357'>(Hombre) \u00daltimo examen de PSA:<\/label><div class='ginput_container ginput_container_text'><input name='input_357' id='input_6_357' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_358\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_358'>(\u00daltimo examen de pr\u00f3stata:<\/label><div class='ginput_container ginput_container_text'><input name='input_358' id='input_6_358' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_359\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_359'>(\u00daltima colonoscopia:<\/label><div class='ginput_container ginput_container_text'><input name='input_359' id='input_6_359' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_360\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_360'>(Hombre) \u00daltima densitometr\u00eda \u00f3sea:<\/label><div class='ginput_container ginput_container_text'><input name='input_360' id='input_6_360' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_361\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_361'>(\u00daltima vacuna contra la neumon\u00eda:<\/label><div class='ginput_container ginput_container_text'><input name='input_361' id='input_6_361' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_362\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_362'>(\u00daltima vacuna contra la gripe:<\/label><div class='ginput_container ginput_container_text'><input name='input_362' id='input_6_362' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_113\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top: 50px; text-decoration: underline;\">Evaluaci\u00f3n de Riesgos de Movilidad<\/h3><\/div><fieldset id=\"field_6_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfNecesita ayuda para caminar?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_182'>\n\t\t\t<div class='gchoice gchoice_6_182_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='No'  id='choice_6_182_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_182_0' id='label_6_182_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_182_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_182' type='radio' value='Yes'  id='choice_6_182_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_182_1' id='label_6_182_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_367\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfSe ha ca\u00eddo antes o se ha lesionado debido a una ca\u00edda?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_367'>\n\t\t\t<div class='gchoice gchoice_6_367_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='No'  id='choice_6_367_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_367_0' id='label_6_367_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_367_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='Yes'  id='choice_6_367_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_367_1' id='label_6_367_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_180\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >\u00bfUsas un<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_180'><div class='gchoice gchoice_6_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='cane?'  id='choice_6_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_1' id='label_6_180_1' class='gform-field-label gform-field-label--type-inline'>\u00bfca\u00f1a?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_180_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.2' type='checkbox'  value='walker?'  id='choice_6_180_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_2' id='label_6_180_2' class='gform-field-label gform-field-label--type-inline'>\u00bfpaseante?<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_180_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.3' type='checkbox'  value='wheel chair?'  id='choice_6_180_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_180_3' id='label_6_180_3' class='gform-field-label gform-field-label--type-inline'>\u00bfSilla de ruedas?<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_183\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTe sientes m\u00e1s d\u00e9bil de lo que sol\u00edas o tienes menos fuerza en tus brazos o piernas?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_183'>\n\t\t\t<div class='gchoice gchoice_6_183_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='No'  id='choice_6_183_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_183_0' id='label_6_183_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_183_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_183' type='radio' value='Yes'  id='choice_6_183_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_183_1' id='label_6_183_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_184\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHa dejado o ha evitado hacer ejercicio \/ actividades diarias por temor a caerse?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_184'>\n\t\t\t<div class='gchoice gchoice_6_184_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='No'  id='choice_6_184_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_184_0' id='label_6_184_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_184_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='Yes'  id='choice_6_184_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_184_1' id='label_6_184_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_185\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene \u00falceras en los pies, juanetes, deformaciones en los dedos o callosidades que le duelen al caminar?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_185'>\n\t\t\t<div class='gchoice gchoice_6_185_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='No'  id='choice_6_185_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_185_0' id='label_6_185_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_185_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_185' type='radio' value='Yes'  id='choice_6_185_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_185_1' id='label_6_185_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_186\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfSe siente mareado cuando se levanta?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_186'>\n\t\t\t<div class='gchoice gchoice_6_186_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='No'  id='choice_6_186_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_186_0' id='label_6_186_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_186_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='Yes'  id='choice_6_186_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_186_1' id='label_6_186_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_187\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_187'>\u00bfCu\u00e1ntas ca\u00eddas ha tenido en los \u00faltimos 12 meses?<\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_6_187' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_188\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfSufri\u00f3 alguna lesi\u00f3n por sus ca\u00eddas?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_188'>\n\t\t\t<div class='gchoice gchoice_6_188_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='No'  id='choice_6_188_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_188_0' id='label_6_188_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_188_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='Yes'  id='choice_6_188_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_188_1' id='label_6_188_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_189\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_189'>Por favor, explique:<\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_6_189' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_190\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 style=\"padding-top:\" 50px; text-decoration: underline;\">Solo para Mujeres<\/h3><\/div><div id=\"field_6_191\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_191'>Edad al primer per\u00edodo menstrual:<\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_6_191' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTodav\u00eda tiene per\u00edodos?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_192'>\n\t\t\t<div class='gchoice gchoice_6_192_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='No'  id='choice_6_192_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_192_0' id='label_6_192_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_192_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_192' type='radio' value='Yes'  id='choice_6_192_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_192_1' id='label_6_192_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_193\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_193'>Fecha o edad del \u00faltimo per\u00edodo menstrual:<\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_6_193' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_194\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_194'>Edad al primer embarazo:<\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_6_194' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_195\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_195'>N\u00famero de embarazos:<\/label><div class='ginput_container ginput_container_text'><input name='input_195' id='input_6_195' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_197\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_197'>N\u00famero de nacimientos:<\/label><div class='ginput_container ginput_container_text'><input name='input_197' id='input_6_197' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAmamanto?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_198'>\n\t\t\t<div class='gchoice gchoice_6_198_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='No'  id='choice_6_198_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_198_0' id='label_6_198_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_198_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Yes'  id='choice_6_198_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_198_1' id='label_6_198_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_199\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfAlguna vez ha tomado terapia de reemplazo hormonal?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_199'>\n\t\t\t<div class='gchoice gchoice_6_199_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='No'  id='choice_6_199_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_199_0' id='label_6_199_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_199_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='Yes'  id='choice_6_199_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_199_1' id='label_6_199_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_200\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_200'>En caso afirmativo, \u00bfcu\u00e1ntos a\u00f1os?<\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_6_200' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_201\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Evaluaci\u00f3n del dolor<\/h3><\/div><fieldset id=\"field_6_202\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene dolor ahora?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_202'>\n\t\t\t<div class='gchoice gchoice_6_202_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='No'  id='choice_6_202_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_202_0' id='label_6_202_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_202_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_202' type='radio' value='Yes'  id='choice_6_202_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_202_1' id='label_6_202_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_203\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_203'>\u00bfD\u00f3nde se encuentra su dolor?<\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_6_203' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_204\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >En una escala del 1 al 10, siendo el 1 un dolor muy leve y el 10 el peor dolor imaginable, \u00bfen qu\u00e9 n\u00famero se encuentra su dolor?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_204'><div class='gchoice gchoice_6_204_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.1' type='checkbox'  value='1'  id='choice_6_204_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_1' id='label_6_204_1' class='gform-field-label gform-field-label--type-inline'>1<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.2' type='checkbox'  value='2'  id='choice_6_204_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_2' id='label_6_204_2' class='gform-field-label gform-field-label--type-inline'>2<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.3' type='checkbox'  value='3'  id='choice_6_204_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_3' id='label_6_204_3' class='gform-field-label gform-field-label--type-inline'>3<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.4' type='checkbox'  value='4'  id='choice_6_204_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_4' id='label_6_204_4' class='gform-field-label gform-field-label--type-inline'>4<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.5' type='checkbox'  value='5'  id='choice_6_204_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_5' id='label_6_204_5' class='gform-field-label gform-field-label--type-inline'>5<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.6' type='checkbox'  value='6'  id='choice_6_204_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_6' id='label_6_204_6' class='gform-field-label gform-field-label--type-inline'>6<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.7' type='checkbox'  value='7'  id='choice_6_204_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_7' id='label_6_204_7' class='gform-field-label gform-field-label--type-inline'>7<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.8' type='checkbox'  value='8'  id='choice_6_204_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_8' id='label_6_204_8' class='gform-field-label gform-field-label--type-inline'>8<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.9' type='checkbox'  value='9'  id='choice_6_204_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_9' id='label_6_204_9' class='gform-field-label gform-field-label--type-inline'>9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_204_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_204.11' type='checkbox'  value='10'  id='choice_6_204_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_204_11' id='label_6_204_11' class='gform-field-label gform-field-label--type-inline'>10<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_205\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_205'>\u00bfC\u00f3mo describir\u00eda el dolor? (por ejemplo, doloroso, punzante, ardiente, palpitante, agudo, sordo)<\/label><div class='ginput_container ginput_container_text'><input name='input_205' id='input_6_205' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_206\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_206'>\u00bfCu\u00e1ndo empez\u00f3 su dolor?<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_6_206' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_207\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_207'>\u00bfHay algo que lo haga mejor o peor?<\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_6_207' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEst\u00e1 tomando medicamentos para el dolor?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_208'>\n\t\t\t<div class='gchoice gchoice_6_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='No'  id='choice_6_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_208_0' id='label_6_208_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_208_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value='Yes'  id='choice_6_208_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_208_1' id='label_6_208_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_209\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_209'>Si es as\u00ed, \u00bfqu\u00e9 medicamento para el dolor?<\/label><div class='ginput_container ginput_container_text'><input name='input_209' id='input_6_209' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_210' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_210' 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_6_6' class='gform_page' data-js='page-field-id-210' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_211\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Revisi\u00f3n de Sistemas<\/h3>\n<strong>\u00bfHa experimentado recientemente alguno de estos s\u00edntomas? Por favor seleccione todas las respuestas v\u00e1lidas<\/strong><\/div><fieldset id=\"field_6_212\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >General<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_212'><div class='gchoice gchoice_6_212_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.1' type='checkbox'  value='Fever\/Chills'  id='choice_6_212_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_1' id='label_6_212_1' class='gform-field-label gform-field-label--type-inline'>Fiebre \/ escalofr\u00edos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_212_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.2' type='checkbox'  value='Fatigue'  id='choice_6_212_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_2' id='label_6_212_2' class='gform-field-label gform-field-label--type-inline'>Fatiga<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_212_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_212.3' type='checkbox'  value='Weight loss\/gain'  id='choice_6_212_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_212_3' id='label_6_212_3' class='gform-field-label gform-field-label--type-inline'>P\u00e9rdida\/ganancia de peso<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_214\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Ojos y visi\u00f3n<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_214'><div class='gchoice gchoice_6_214_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.1' type='checkbox'  value='Glasses\/contacts'  id='choice_6_214_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_1' id='label_6_214_1' class='gform-field-label gform-field-label--type-inline'>Gafas\/lentes de contacto<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.2' type='checkbox'  value='Eye disease or injury'  id='choice_6_214_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_2' id='label_6_214_2' class='gform-field-label gform-field-label--type-inline'>Enfermedad o lesi\u00f3n ocular<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.3' type='checkbox'  value='Eye pain or pressure'  id='choice_6_214_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_3' id='label_6_214_3' class='gform-field-label gform-field-label--type-inline'>Dolor o presi\u00f3n en los ojos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_214_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_214.4' type='checkbox'  value='Blurred or Double vision'  id='choice_6_214_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_214_4' id='label_6_214_4' class='gform-field-label gform-field-label--type-inline'>Visi\u00f3n borrosa o doble<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_215\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Orejas, nariz, garganta<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_215'><div class='gchoice gchoice_6_215_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.1' type='checkbox'  value='Hearing loss'  id='choice_6_215_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_1' id='label_6_215_1' class='gform-field-label gform-field-label--type-inline'>Perdida de la audici\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.2' type='checkbox'  value='Ringing in ears'  id='choice_6_215_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_2' id='label_6_215_2' class='gform-field-label gform-field-label--type-inline'>Zumbidos en los o\u00eddos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.3' type='checkbox'  value='Ear ache or drainage'  id='choice_6_215_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_3' id='label_6_215_3' class='gform-field-label gform-field-label--type-inline'>Dolor de o\u00eddo o drenaje<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.4' type='checkbox'  value='Sinus problems'  id='choice_6_215_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_4' id='label_6_215_4' class='gform-field-label gform-field-label--type-inline'>Problemas sinusales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.5' type='checkbox'  value='Nose bleeds'  id='choice_6_215_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_5' id='label_6_215_5' class='gform-field-label gform-field-label--type-inline'>Sangrado de nariz<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.6' type='checkbox'  value='Dental problems'  id='choice_6_215_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_6' id='label_6_215_6' class='gform-field-label gform-field-label--type-inline'>Problemas dentales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.7' type='checkbox'  value='Dentures'  id='choice_6_215_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_7' id='label_6_215_7' class='gform-field-label gform-field-label--type-inline'>Dentaduras postizas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.8' type='checkbox'  value='Mouth sores'  id='choice_6_215_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_8' id='label_6_215_8' class='gform-field-label gform-field-label--type-inline'>\u00dalceras en la boca<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.9' type='checkbox'  value='Sore throat'  id='choice_6_215_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_9' id='label_6_215_9' class='gform-field-label gform-field-label--type-inline'>Dolor de garganta<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.11' type='checkbox'  value='Difficulty\/painful swallowing'  id='choice_6_215_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_11' id='label_6_215_11' class='gform-field-label gform-field-label--type-inline'>Dificultad\/dolor al tragar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.12' type='checkbox'  value='Hoarseness or voice change'  id='choice_6_215_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_12' id='label_6_215_12' class='gform-field-label gform-field-label--type-inline'>Ronquera o cambio de voz<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_215_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_215.13' type='checkbox'  value='Swollen glands in neck'  id='choice_6_215_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_215_13' id='label_6_215_13' class='gform-field-label gform-field-label--type-inline'>Gl\u00e1ndulas inflamadas en el cuello<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_216\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Coraz\u00f3n\/Cardiovascular<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_216'><div class='gchoice gchoice_6_216_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.1' type='checkbox'  value='Chest pain'  id='choice_6_216_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_1' id='label_6_216_1' class='gform-field-label gform-field-label--type-inline'>Dolor de Pecho<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.2' type='checkbox'  value='Heart Palpitations'  id='choice_6_216_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_2' id='label_6_216_2' class='gform-field-label gform-field-label--type-inline'>Palpitaciones de coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.3' type='checkbox'  value='Dizziness'  id='choice_6_216_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_3' id='label_6_216_3' class='gform-field-label gform-field-label--type-inline'>Mareo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_216_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_216.4' type='checkbox'  value='Swollen legs\/ankles'  id='choice_6_216_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_216_4' id='label_6_216_4' class='gform-field-label gform-field-label--type-inline'>Piernas\/tobillos hinchados<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_217\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Respiratorio<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_217'><div class='gchoice gchoice_6_217_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.1' type='checkbox'  value='Frequent Coughing'  id='choice_6_217_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_1' id='label_6_217_1' class='gform-field-label gform-field-label--type-inline'>Tos frecuente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.2' type='checkbox'  value='Spitting up blood'  id='choice_6_217_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_2' id='label_6_217_2' class='gform-field-label gform-field-label--type-inline'>Escupiendo sangre<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.3' type='checkbox'  value='Wheezing or asthma'  id='choice_6_217_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_3' id='label_6_217_3' class='gform-field-label gform-field-label--type-inline'>Sibilancias o asma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_217_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_217.4' type='checkbox'  value='Shortness of breath'  id='choice_6_217_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_217_4' id='label_6_217_4' class='gform-field-label gform-field-label--type-inline'>Dificultad para respirar<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_218\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Endocrino<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_218'><div class='gchoice gchoice_6_218_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.1' type='checkbox'  value='Loss of hair\/thinning hair'  id='choice_6_218_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_1' id='label_6_218_1' class='gform-field-label gform-field-label--type-inline'>P\u00e9rdida\/debilitamiento de cabello<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_218_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.2' type='checkbox'  value='Heat\/cold intolerance'  id='choice_6_218_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_2' id='label_6_218_2' class='gform-field-label gform-field-label--type-inline'>Intolerancia al calor\/fr\u00edo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_218_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_218.3' type='checkbox'  value='Excessive thirst'  id='choice_6_218_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_218_3' id='label_6_218_3' class='gform-field-label gform-field-label--type-inline'>Sed excesiva<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_219\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Gastrointestinal<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_219'><div class='gchoice gchoice_6_219_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.1' type='checkbox'  value='Loss of appetite'  id='choice_6_219_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_1' id='label_6_219_1' class='gform-field-label gform-field-label--type-inline'>P\u00e9rdida del apetito<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.2' type='checkbox'  value='Nausea or Vomiting'  id='choice_6_219_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_2' id='label_6_219_2' class='gform-field-label gform-field-label--type-inline'>N\u00e1useas o v\u00f3mitos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.3' type='checkbox'  value='Stomach pain'  id='choice_6_219_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_3' id='label_6_219_3' class='gform-field-label gform-field-label--type-inline'>Dolor de est\u00f3mago<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.4' type='checkbox'  value='Frequent diarrhea'  id='choice_6_219_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_4' id='label_6_219_4' class='gform-field-label gform-field-label--type-inline'>Diarrea frecuente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.5' type='checkbox'  value='Constipation'  id='choice_6_219_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_5' id='label_6_219_5' class='gform-field-label gform-field-label--type-inline'>Constipaci\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_219_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_219.6' type='checkbox'  value='Blood in stool'  id='choice_6_219_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_219_6' id='label_6_219_6' class='gform-field-label gform-field-label--type-inline'>Sangre en las heces<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_220\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Genitourinario<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_220'><div class='gchoice gchoice_6_220_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.1' type='checkbox'  value='Frequent urination'  id='choice_6_220_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_1' id='label_6_220_1' class='gform-field-label gform-field-label--type-inline'>Evacuaci\u00f3n urinaria frecuente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.2' type='checkbox'  value='Burning or painful urination'  id='choice_6_220_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_2' id='label_6_220_2' class='gform-field-label gform-field-label--type-inline'>Ardor o dolor al orinar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.3' type='checkbox'  value='Blood in urine'  id='choice_6_220_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_3' id='label_6_220_3' class='gform-field-label gform-field-label--type-inline'>Sangre en la orina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.4' type='checkbox'  value='Incontinence or dribbling'  id='choice_6_220_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_4' id='label_6_220_4' class='gform-field-label gform-field-label--type-inline'>Incontinencia o goteo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.5' type='checkbox'  value='Urgency'  id='choice_6_220_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_5' id='label_6_220_5' class='gform-field-label gform-field-label--type-inline'>Urgencia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.6' type='checkbox'  value='Vaginal discharge'  id='choice_6_220_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_6' id='label_6_220_6' class='gform-field-label gform-field-label--type-inline'>Flujo vaginal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.7' type='checkbox'  value='Painful\/irregular periods'  id='choice_6_220_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_7' id='label_6_220_7' class='gform-field-label gform-field-label--type-inline'>Per\u00edodos dolorosos\/irregulares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_220_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_220.8' type='checkbox'  value='Sexual difficulty'  id='choice_6_220_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_220_8' id='label_6_220_8' class='gform-field-label gform-field-label--type-inline'>Dificultad sexual<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_221\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Psiqui\u00e1trico<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_221'><div class='gchoice gchoice_6_221_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.1' type='checkbox'  value='Depression'  id='choice_6_221_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_1' id='label_6_221_1' class='gform-field-label gform-field-label--type-inline'>Depresi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.2' type='checkbox'  value='Anxiety\/Nervousness'  id='choice_6_221_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_2' id='label_6_221_2' class='gform-field-label gform-field-label--type-inline'>Ansiedad\/nerviosismo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.3' type='checkbox'  value='Sleep Disorders'  id='choice_6_221_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_3' id='label_6_221_3' class='gform-field-label gform-field-label--type-inline'>Trastornos del sue\u00f1o<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_221_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_221.4' type='checkbox'  value='Suicidal Thoughts'  id='choice_6_221_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_221_4' id='label_6_221_4' class='gform-field-label gform-field-label--type-inline'>Pensamientos suicidas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_222\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Hematolog\u00eda\/Linf\u00e1tica<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_222'><div class='gchoice gchoice_6_222_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.1' type='checkbox'  value='Easily bruise or bleed'  id='choice_6_222_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_1' id='label_6_222_1' class='gform-field-label gform-field-label--type-inline'>Salen hematomas o sangra f\u00e1cilmente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.2' type='checkbox'  value='Anemia'  id='choice_6_222_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_2' id='label_6_222_2' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.3' type='checkbox'  value='Slow to heal'  id='choice_6_222_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_3' id='label_6_222_3' class='gform-field-label gform-field-label--type-inline'>Lento para sanar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_222_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_222.4' type='checkbox'  value='History of transfusion'  id='choice_6_222_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_222_4' id='label_6_222_4' class='gform-field-label gform-field-label--type-inline'>Historial de transfusi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_223\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Musculoesquel\u00e9tico<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_223'><div class='gchoice gchoice_6_223_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.1' type='checkbox'  value='Joint pain or stiffness'  id='choice_6_223_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_1' id='label_6_223_1' class='gform-field-label gform-field-label--type-inline'>Dolor o rigidez en las articulaciones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.2' type='checkbox'  value='Back pain'  id='choice_6_223_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_2' id='label_6_223_2' class='gform-field-label gform-field-label--type-inline'>Dolor de espalda<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.3' type='checkbox'  value='Muscle pain or cramps'  id='choice_6_223_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_3' id='label_6_223_3' class='gform-field-label gform-field-label--type-inline'>Dolor muscular o calambres<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.4' type='checkbox'  value='Cold arms or legs'  id='choice_6_223_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_4' id='label_6_223_4' class='gform-field-label gform-field-label--type-inline'>Brazos o piernas fr\u00edas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_223_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_223.5' type='checkbox'  value='Difficulty walking'  id='choice_6_223_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_223_5' id='label_6_223_5' class='gform-field-label gform-field-label--type-inline'>Dificultad para caminar<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_224\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Piel y Seno<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_224'><div class='gchoice gchoice_6_224_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.1' type='checkbox'  value='Rash or Itching'  id='choice_6_224_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_1' id='label_6_224_1' class='gform-field-label gform-field-label--type-inline'>Sarpullido o picaz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.2' type='checkbox'  value='Lesion or change in skin color'  id='choice_6_224_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_2' id='label_6_224_2' class='gform-field-label gform-field-label--type-inline'>Lesi\u00f3n o cambio en el color de la piel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.3' type='checkbox'  value='Breast mass\/lump'  id='choice_6_224_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_3' id='label_6_224_3' class='gform-field-label gform-field-label--type-inline'>Masa mamaria \/ bulto<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.4' type='checkbox'  value='Nipple discharge \/ retraction'  id='choice_6_224_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_4' id='label_6_224_4' class='gform-field-label gform-field-label--type-inline'>Secreci\u00f3n \/ retracci\u00f3n del pez\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_224_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_224.5' type='checkbox'  value='Open or non-healing wound'  id='choice_6_224_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_224_5' id='label_6_224_5' class='gform-field-label gform-field-label--type-inline'>Herida abierta o no cicatrizante<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_225\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >Neurol\u00f3gico<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_225'><div class='gchoice gchoice_6_225_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.1' type='checkbox'  value='Frequent headache'  id='choice_6_225_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_1' id='label_6_225_1' class='gform-field-label gform-field-label--type-inline'>Dolor de cabeza frecuente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.2' type='checkbox'  value='Lightheaded or dizzy'  id='choice_6_225_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_2' id='label_6_225_2' class='gform-field-label gform-field-label--type-inline'>V\u00e9rtigo o Mareado<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.3' type='checkbox'  value='Confusion'  id='choice_6_225_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_3' id='label_6_225_3' class='gform-field-label gform-field-label--type-inline'>Confusi\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.4' type='checkbox'  value='Speech difficulty'  id='choice_6_225_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_4' id='label_6_225_4' class='gform-field-label gform-field-label--type-inline'>Dificultad para hablar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.5' type='checkbox'  value='Seizure activity'  id='choice_6_225_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_5' id='label_6_225_5' class='gform-field-label gform-field-label--type-inline'>Actividad convulsiva<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.6' type='checkbox'  value='Numbness or tingling'  id='choice_6_225_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_6' id='label_6_225_6' class='gform-field-label gform-field-label--type-inline'>Entumecimiento u hormigueo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_225_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_225.7' type='checkbox'  value='Weakness in arms or legs'  id='choice_6_225_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_225_7' id='label_6_225_7' class='gform-field-label gform-field-label--type-inline'>Debilidad en brazos o piernas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_376' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_376' 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_6_7' class='gform_page' data-js='page-field-id-376' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_227\" 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\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Cuestionario acerca de Depresi\u00f3n<\/h3>\n<p>Durante las \u00faltimas 2 semanas, que tan seguido ha tenido molestias debido a los siguientes problemas?<\/div><fieldset id=\"field_6_378\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Poco inter\u00e9s o placer en hacer cosas<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_378'>\n\t\t\t<div class='gchoice gchoice_6_378_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Not at all'  id='choice_6_378_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_0' id='label_6_378_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Several days'  id='choice_6_378_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_1' id='label_6_378_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='More than half the days'  id='choice_6_378_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_2' id='label_6_378_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_378_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_378' type='radio' value='Nearly every day'  id='choice_6_378_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_378_3' id='label_6_378_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_379\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Se ha sentido deca\u00eddo(a), deprimido(a) o sin esperanzas<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_379'>\n\t\t\t<div class='gchoice gchoice_6_379_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Not at all'  id='choice_6_379_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_0' id='label_6_379_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Several days'  id='choice_6_379_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_1' id='label_6_379_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='More than half the days'  id='choice_6_379_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_2' id='label_6_379_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_379_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_379' type='radio' value='Nearly every day'  id='choice_6_379_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_379_3' id='label_6_379_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_380\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >3. Ha tenido dificultades para quedarse o permanecer dormido(a), o ha dormido demasiado<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_380'>\n\t\t\t<div class='gchoice gchoice_6_380_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Not at all'  id='choice_6_380_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_0' id='label_6_380_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Several days'  id='choice_6_380_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_1' id='label_6_380_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='More than half the days'  id='choice_6_380_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_2' id='label_6_380_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_380_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_380' type='radio' value='Nearly every day'  id='choice_6_380_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_380_3' id='label_6_380_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_381\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Se ha sentido cansado(a) o con poca energ\u00eda<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_381'>\n\t\t\t<div class='gchoice gchoice_6_381_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Not at all'  id='choice_6_381_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_0' id='label_6_381_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Several days'  id='choice_6_381_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_1' id='label_6_381_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='More than half the days'  id='choice_6_381_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_2' id='label_6_381_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_381_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_381' type='radio' value='Nearly every day'  id='choice_6_381_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_381_3' id='label_6_381_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_382\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Sin apetito o ha comido en exceso<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_382'>\n\t\t\t<div class='gchoice gchoice_6_382_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Not at all'  id='choice_6_382_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_0' id='label_6_382_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Several days'  id='choice_6_382_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_1' id='label_6_382_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='More than half the days'  id='choice_6_382_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_2' id='label_6_382_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_382_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_382' type='radio' value='Nearly every day'  id='choice_6_382_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_382_3' id='label_6_382_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_383\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Se ha sentido mal con usted mismo(a) - o que es un fracaso, o que ha quedao mal con usted mismo(a) o con su familia<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_383'>\n\t\t\t<div class='gchoice gchoice_6_383_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Not at all'  id='choice_6_383_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_0' id='label_6_383_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Several days'  id='choice_6_383_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_1' id='label_6_383_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='More than half the days'  id='choice_6_383_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_2' id='label_6_383_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_383_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_383' type='radio' value='Nearly every day'  id='choice_6_383_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_383_3' id='label_6_383_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_384\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Ha tenido dificultad para concentrarse en ciertas actividades, tales como ver el peri\u00f3dico o ver la televisi\u00f3n<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_384'>\n\t\t\t<div class='gchoice gchoice_6_384_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Not at all'  id='choice_6_384_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_0' id='label_6_384_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Several days'  id='choice_6_384_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_1' id='label_6_384_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='More than half the days'  id='choice_6_384_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_2' id='label_6_384_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_384_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_384' type='radio' value='Nearly every day'  id='choice_6_384_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_384_3' id='label_6_384_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_386\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >8. \u00bfSe ha movido o hablado tan lento que otras personas podr\u00edan haberlo notado? O lo contrario - muy inquieto(a) o agitado(a) que ha estado movi\u00e9ndose mucho m\u00e1s de lo normal<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_386'>\n\t\t\t<div class='gchoice gchoice_6_386_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Not at all'  id='choice_6_386_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_0' id='label_6_386_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Several days'  id='choice_6_386_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_1' id='label_6_386_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='More than half the days'  id='choice_6_386_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_2' id='label_6_386_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_386_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_386' type='radio' value='Nearly every day'  id='choice_6_386_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_386_3' id='label_6_386_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_385\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >9. Pensamientos de que estar\u00eda mejor muerto(a) o de lastimarse de alguna manera<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_385'>\n\t\t\t<div class='gchoice gchoice_6_385_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Not at all'  id='choice_6_385_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_0' id='label_6_385_0' class='gform-field-label gform-field-label--type-inline'>Ning\u00fan d\u00eda<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Several days'  id='choice_6_385_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_1' id='label_6_385_1' class='gform-field-label gform-field-label--type-inline'>Varios d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='More than half the days'  id='choice_6_385_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_2' id='label_6_385_2' class='gform-field-label gform-field-label--type-inline'>Mas de la mita de los d\u00edas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_385_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_385' type='radio' value='Nearly every day'  id='choice_6_385_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_385_3' id='label_6_385_3' class='gform-field-label gform-field-label--type-inline'>Casi todos los d\u00edas<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_226' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_226' 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_6_8' class='gform_page' data-js='page-field-id-226' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_377\" 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\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Directivas Anticipadas<\/h3><\/div><fieldset id=\"field_6_228\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene un Poder Legal M\u00e9dico?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_228'>\n\t\t\t<div class='gchoice gchoice_6_228_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='No'  id='choice_6_228_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_228_0' id='label_6_228_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_228_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_228' type='radio' value='Yes'  id='choice_6_228_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_228_1' id='label_6_228_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_229\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene una Directiva Anticipada?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_229'>\n\t\t\t<div class='gchoice gchoice_6_229_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='No'  id='choice_6_229_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_229_0' id='label_6_229_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_229_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_229' type='radio' value='Yes'  id='choice_6_229_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_229_1' id='label_6_229_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene un Testamento en Vida?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_230'>\n\t\t\t<div class='gchoice gchoice_6_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='No'  id='choice_6_230_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_230_0' id='label_6_230_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='Yes'  id='choice_6_230_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_230_1' id='label_6_230_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_231\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfTiene una tarjeta de donante?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_231'>\n\t\t\t<div class='gchoice gchoice_6_231_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='No'  id='choice_6_231_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_231_0' id='label_6_231_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_231_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_231' type='radio' value='Yes'  id='choice_6_231_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_231_1' id='label_6_231_1' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_232\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_232'>Por favor, facilite una copia del documento:<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='134217728' \/><input name='input_232' id='input_6_232' type='file' class='medium' aria-describedby=\"gfield_upload_rules_6_232\" onchange='javascript:gformValidateFileSize( this, 134217728 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_232'>Max. file size: 128 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_6_232'><\/div> <\/div><\/div><div id=\"field_6_233\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><strong>Enumere los nombres y las direcciones de los m\u00e9dicos a los que desea que le enviemos la correspondencia:<\/strong><\/div><div id=\"field_6_234\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_234'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_234' id='input_6_234' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_237\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_6_237'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_237' id='input_6_237' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_236\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_236'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_236' id='input_6_236' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_235\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half 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_6_235'>Nombre del m\u00e9dico y tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_6_235' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_238\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Como paciente usted reconoce que, al completar este formulario, constituye el resumen completo de su historial cl\u00ednico.<\/strong><\/p>\n<p><small>Al ingresar mi nombre, acepto que la firma y las iniciales ser\u00e1n la representaci\u00f3n electr\u00f3nica de mi firma e iniciales para todos los prop\u00f3sitos cuando \u00daselos en este formulario, al igual que una firma en l\u00e1piz y papel o una inicial<\/small><\/p><\/div><div id=\"field_6_239\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_239'>Firma del paciente\/responsable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_6_239' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_242\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half 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_6_242'>Fecha<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_242' id='input_6_242' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_242_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_242_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_242' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_337\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >\u00bfAcepta firmar electr\u00f3nicamente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_337.1' id='input_6_337_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_6_337_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_337.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_337.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_243\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_243'>Firma de la enfermera<\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_6_243' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_244\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half 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_6_244'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_244' id='input_6_244' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_244_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_244_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_244' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_338\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/legend><div class='ginput_container ginput_container_consent'><input name='input_338.1' id='input_6_338_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_338_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_338.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_338.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_245\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_245'>Firma del m\u00e9dico<\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_6_245' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_340\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half 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_6_340'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_340' id='input_6_340' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_340_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_340_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_340' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_339\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento<\/legend><div class='ginput_container ginput_container_consent'><input name='input_339.1' id='input_6_339_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_339_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_339.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_339.3' value='4' 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_6_247' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_247' 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_6_9' class='gform_page' data-js='page-field-id-247' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_249\" class=\"gfield gfield--type-html gfield--input-type-html pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">GENERAL CONSENT FOR TREATMENT, FINANCIAL AGREEMENT, AND\nCOMMUNICATION AUTHORIZATION<\/h3>\n<h4>Precision Healthcare Specialists, LLC<\/h4>\n<p>We are pleased to share that we are now part of Precision Healthcare Specialists. This transition allows us to expand our resources and continue strengthening the care we provide to our patients and community.<\/p>\n\n<p><strong>What this means for you:<\/strong><\/p>\n\n<ul>\n<li><strong>Your care will not change.<\/strong> You will continue to see the same physicians and care team you know and trust.<\/li>\n\n<li><strong>Your treatment and services remain the same.<\/strong> There is no change to the quality or approach to your care.<\/li>\n\n<li><strong>Billing statements and other administrative forms may reflect a new name.<\/strong> You may see <strong>Precision Healthcare Specialists<\/strong> listed on billing and related communications.<\/li>\n<\/ul>\n\n<p>If you have any questions about this update or your account, please contact our office. We are happy to assist you. Thank you for trusting us with your care.<\/p>\n\n<hr\/>\n\n<h4>Consent for Medical Evaluation and Treatment<\/h4>\n\n<p>I voluntarily consent to receive medical evaluation, diagnostic procedures, and treatment from Precision Healthcare Specialists (\u201cthe Practice\u201d), including its physicians, advanced practice providers, nurses, technicians, students, trainees, and other healthcare personnel involved in my care.<\/p>\n\n<p>My care may include:<\/p>\n\n<ul>\n<li>Medical evaluation and examination<\/li>\n\n<li>Diagnostic testing and procedures<\/li>\n\n<li>Laboratory testing and imaging<\/li>\n\n<li>Administration of medications<\/li>\n\n<li>Routine medical treatment and care<\/li>\n\n<li>Telehealth services when appropriate<\/li>\n<\/ul>\n\n<p>I understand that medications, injections, infusions, or other therapeutic treatments may be prescribed or administered as part of my care. These treatments may involve potential risks or side effects, including but not limited to allergic reactions, medication side effects, infection, bleeding, or other complications. When clinically appropriate, my healthcare provider may discuss the purpose, risks, benefits, and alternatives to these treatments, and I have the opportunity to ask questions before proceeding.<\/p>\n\n<p>My healthcare provider may discuss with me the nature and purpose of proposed treatments, the material risks and benefits, and reasonable alternatives, including the option of no treatment, when clinically appropriate. I have the right to ask questions about my condition, proposed treatment, risks, benefits, and alternatives, and I have the right to refuse treatment to the extent permitted by law. I understand that refusal of recommended care may affect my health outcomes.<\/p>\n\n<p>I am responsible for informing my healthcare provider of my medical history, medications, allergies, and any changes in my condition.<\/p>\n\n<hr\/>\n\n<h4>Care Team Participation and Coordination of Care<\/h4>\n\n<p>I understand that individuals involved in my care may include physicians, advanced practice providers, nurses, medical assistants, technicians, trainees, students, or other authorized healthcare personnel working under appropriate supervision.<\/p>\n\n<p>I authorize the Practice to use and disclose my medical information as necessary for treatment, payment, and healthcare operations, including coordination with other healthcare providers involved in my care, consistent with applicable federal and state privacy laws.<\/p>\n\n<hr\/>\n\n<h4>Photography and Documentation for Treatment Purposes<\/h4>\n\n<p>I understand that photographs, video, or other recordings may be taken for purposes of diagnosis, treatment, medical documentation, quality improvement, or healthcare operations. These images will be handled in accordance with privacy and security standards and applicable law.<\/p>\n\n<hr\/>\n\n<h4>Use of Technology and AI-Assisted Documentation<\/h4>\n\n<p>The Practice may use technology to support high-quality patient care and accurate medical documentation, including voice recognition, ambient listening tools, and artificial intelligence (AI)\u2013assisted documentation systems.<\/p>\n\n<p>Telehealth services and other electronic technologies rely on communication systems that may occasionally experience interruptions, delays, or technical failures that could require rescheduling or an in-person visit.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Technology may be used during my visit to assist with documentation.<\/li>\n\n<li>Conversations may be electronically processed to create medical records.<\/li>\n\n<li>My healthcare provider reviews and approves all documentation entered into my medical record.<\/li>\n\n<li>These tools support clinical documentation and do not replace medical judgment.<\/li>\n\n<li>Information collected is handled in accordance with applicable privacy and security laws.<\/li>\n<\/ul>\n\n<p>I understand that I may request that these technologies not be used during my visit and that my care will not be affected if I decline.<\/p><\/div><fieldset id=\"field_6_401\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to use of AI or technology-assisted documentation<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_6_401'>\n\t\t\t<div class='gchoice gchoice_6_401_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_401' type='radio' value='I agree to the use of AI or technology-assisted documentation during my visits.'  id='choice_6_401_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_401_0' id='label_6_401_0' class='gform-field-label gform-field-label--type-inline'>I agree to the use of AI or technology-assisted documentation during my visits.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_401_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_401' type='radio' value='I decline the use of AI or technology-assisted documentation during my visits.'  id='choice_6_401_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_401_1' id='label_6_401_1' class='gform-field-label gform-field-label--type-inline'>I decline the use of AI or technology-assisted documentation during my visits.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_402\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >\n<hr\/>\n\n<h4>Procedural Acknowledgment<\/h4>\n\n<p>I understand that certain procedures, treatments, or interventions may involve additional risks and may require separate informed consent documents. When applicable, these procedures will be explained to me, including risks, benefits, and alternatives, and I will have the opportunity to ask questions before agreeing to proceed.<\/p>\n\n<hr\/>\n\n<h4>Responsabilidad financiera<\/h4>\n\n<p>I understand and agree that:<\/p>\n\n<ul>\n<li>All professional services rendered are the responsibility of the patient or designated party.<\/li>\n\n<li>Payment is due at the time services are rendered unless other arrangements have been made in advance.<\/li>\n\n<li>I am responsible for any balance not paid by my insurance carrier, including copayments, coinsurance, deductibles, non-covered services, and denied claims.<\/li>\n\n<li>Verification of insurance benefits is not a guarantee of payment. Coverage is determined by my insurance plan.<\/li>\n\n<li>I agree to provide current and accurate insurance information and notify the Practice of any changes.<\/li>\n\n<li>If my account becomes delinquent, it may be referred for collection, and I may be responsible for reasonable collection costs, attorney fees, and court costs where permitted by law.<\/li>\n<\/ul>\n\n<hr\/>\n\n<h4>Asignaci\u00f3n de beneficios<\/h4>\n\n<p>I hereby assign and authorize direct payment of all medical and surgical benefits, including major medical benefits, to Precision Healthcare Specialists for services rendered to me or my dependents.<\/p>\n\n<p>I authorize my insurance carrier(s), including Medicare, private insurance, and any other health or medical plan, to issue payment directly to Precision Healthcare Specialists. I understand that I remain financially responsible for any amount not covered by insurance.<\/p>\n\n<p>A photocopy or electronic copy of this authorization shall be considered as valid as the original.<\/p>\n\n<hr\/>\n\n<h4>Authorization to Release Information for Payment<\/h4>\n\n<p>I authorize the Practice to release information necessary to:<\/p>\n\n<ul>\n<li>Process insurance claims<\/li>\n\n<li>Obtain payment<\/li>\n\n<li>Coordinate benefits with payers<\/li>\n<\/ul>\n\n<p>This authorization remains in effect until revoked by me in writing.<\/p>\n\n<hr\/>\n\n<h4>Communication Authorization and Consent to Contact<\/h4>\n\n<p>I authorize Precision Healthcare Specialists, its employees, agents, contractors, and affiliates to contact me using the contact information I have provided regarding my healthcare, appointments, treatment, billing, office policies, updates or changes and related services.<\/p>\n\n<p>Communication methods may include:<\/p>\n\n<ul>\n<li>Telephone calls<\/li>\n\n<li>Text messages (SMS)<\/li>\n\n<li>Voicemail messages<\/li>\n\n<li>Env\u00ede un correo electr\u00f3nico a<\/li>\n\n<li>Patient portal messaging<\/li>\n\n<li>Automated or prerecorded voice messages<\/li>\n\n<li>Other electronic communication methods<\/li>\n<\/ul>\n\n<p>These communications may include appointment reminders, care coordination, test results, billing matters, practice updates, health education, and information about services that may be relevant to my care.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Calls or messages may be sent using automated dialing systems or prerecorded messages.<\/li>\n\n<li>Messages may be left on voicemail or with another person unless I notify the Practice otherwise.<\/li>\n\n<li>Standard message and data rates may apply depending on my mobile carrier plan.<\/li>\n\n<li>I may opt out of certain communications at any time by notifying the Practice or following opt-out instructions (such as replying STOP to text messages).<\/li>\n<\/ul>\n\n<p>Signing this authorization is voluntary. My treatment will not be conditioned upon providing consent to receive communications.<\/p>\n<\/div><fieldset id=\"field_6_403\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to receive electronic communications<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_6_403'>\n\t\t\t<div class='gchoice gchoice_6_403_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_403' type='radio' value='I agree to receive electronic communications'  id='choice_6_403_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_403_0' id='label_6_403_0' class='gform-field-label gform-field-label--type-inline'>I agree to receive electronic communications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_403_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_403' type='radio' value='I decline to receive electronic communications'  id='choice_6_403_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_403_1' id='label_6_403_1' class='gform-field-label gform-field-label--type-inline'>I decline to receive electronic communications<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_405\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr\/>\n\n<h4>Consent to Contact for Marketing &amp; Communications<\/h4>\n\n<p>By providing my contact information, I consent to receive communications from Precision Healthcare Specialists and its affiliated providers, which may include appointment reminders, follow-up care information, educational content, and information about services, programs, or events that may be of interest to me.<\/p>\n\n<p>These communications may be delivered via phone call, voicemail, text message (SMS), or email, using the contact information I have provided.<\/p>\n\n<p>I understand that:<\/p>\n\n<ul>\n<li>Consent to receive marketing or promotional communications is voluntary and is not a condition of receiving treatment or services<\/li>\n\n<li>Message and data rates may apply for text messages<\/li>\n\n<li>I may opt out at any time by following the unsubscribe instructions included in communications or by contacting the practice directly<\/li>\n<\/ul><\/div><fieldset id=\"field_6_404\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Consent to receive marketing communications<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_6_404'>\n\t\t\t<div class='gchoice gchoice_6_404_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_404' type='radio' value='I agree to receive marketing communications'  id='choice_6_404_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_404_0' id='label_6_404_0' class='gform-field-label gform-field-label--type-inline'>I agree to receive marketing communications<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_404_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_404' type='radio' value='I decline to receive marketing communications'  id='choice_6_404_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_404_1' id='label_6_404_1' class='gform-field-label gform-field-label--type-inline'>I decline to receive marketing communications<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_406\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><hr\/>\n\n<h4>Directivas Anticipadas<\/h4>\n\n<p>I understand that I have the right under Florida law to make decisions regarding my medical care, including the right to accept or refuse treatment and the right to formulate advance directives. Information regarding advance directives is available to me upon request.<\/p>\n\n<hr\/>\n\n<h4>Duration of Consent<\/h4>\n\n<p>This consent and authorization will remain in effect for the duration of my treatment with Precision Healthcare Specialists unless revoked by me in writing.<\/p>\n\n<h4>Patient Acknowledgment and Signature<\/h4>\n\n<p>I have read and understand this document. I have had the opportunity to ask questions about my care, and my questions have been answered to my satisfaction. I voluntarily consent to medical evaluation and treatment and agree to the financial and communication terms described above.<\/p>\n<\/div><div id=\"field_6_251\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_251'>Firma del paciente\/responsable<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_251' id='input_6_251' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_407\" 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_6_407'>Relaci\u00f3n con el paciente<\/label><div class='ginput_container ginput_container_text'><input name='input_407' id='input_6_407' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_250\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half 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_6_250'>Fecha<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_250' id='input_6_250' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_250_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_250_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_250' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_341\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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 para firmar electr\u00f3nicamente.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_341.1' id='input_6_341_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_6_341_1' >Acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_341.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_341.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_252\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_252'>Testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_6_252' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_253\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half 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_6_253'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_253' id='input_6_253' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_253_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_253_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_253' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_342\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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 para firmar electr\u00f3nicamente.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_342.1' id='input_6_342_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_342_1' >Acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_342.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_342.3' value='4' 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_6_262' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_262' 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_6_10' class='gform_page' data-js='page-field-id-262' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_315\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">HIPAA para la Divulgaci\u00f3n de Informaci\u00f3n del Paciente<\/h3>\n<\/div><fieldset id=\"field_6_410\" 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 field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I have read the HIPAA information below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_410.1' id='input_6_410_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_6_410_1' ><p>I am a patient of Advocate Radiation Oncology (Precision Healthcare Specialists) and understand that I am required to inform the facility of the persons to whom they may disclose my medical information. These assigned persons may be changed at any time by myself. This disclosure becomes effective on the date it is signed and will continue until it is cancelled, changed, altered or amended by myself or my appointed legal representative.  This facility has notified me that they have a listing of all the persons and agencies or payers to whom my medical information may be disclosed during the course of any medical treatment by this facility.<\/p>  <p>HE LE\u00cdDO EL FORMULARIO DE DIVULGACI\u00d3N AUTORIZADA Y LO ENTIENDO.<br \/><\/p>  <p>Entiendo que tengo el derecho de revocar esta autorizaci\u00f3n, por escrito, en cualquier momento, excepto cuando ya se hayan hecho usos o divulgaciones con base en mi permiso original. Es posible que no pueda revocar esta autorizaci\u00f3n si su prop\u00f3sito era obtener un seguro. Para revocar esta autorizaci\u00f3n, debo hacerlo por escrito y enviarla a la parte divulgadora correspondiente.<\/p>  <p>Entiendo que el uso y divulgaciones que ya se han realizado en base a mi permiso original no se pueden retirar.<\/p>  <p>Entiendo que es posible que la informaci\u00f3n utilizada o divulgada con mi permiso pueda ser divulgada nuevamente por el destinatario y ya no est\u00e9 protegida por los Est\u00e1ndares de privacidad de HIPAA.<\/p>  <p>Entiendo que el tratamiento por parte de cualquier parte no puede estar condicionado a mi firma de esta autorizaci\u00f3n (a menos que el tratamiento se busque solo para crear informaci\u00f3n m\u00e9dica para un tercero o para participar en un estudio de investigaci\u00f3n) y que puedo tener derecho a negarme a firmar esta autorizaci\u00f3n.<\/p>  <p>Recibir\u00e9 una copia de esta autorizaci\u00f3n despu\u00e9s de haberla firmado. Una copia de esta autorizaci\u00f3n es tan v\u00e1lida como el original.<\/p><\/label><input type='hidden' name='input_410.2' value='&lt;p&gt;I am a patient of Advocate Radiation Oncology (Precision Healthcare Specialists) and understand that I am required to inform the facility of the persons to whom they may disclose my medical information. These assigned persons may be changed at any time by myself. This disclosure becomes effective on the date it is signed and will continue until it is cancelled, changed, altered or amended by myself or my appointed legal representative.  This facility has notified me that they have a listing of all the persons and agencies or payers to whom my medical information may be disclosed during the course of any medical treatment by this facility.&lt;\/p&gt;  &lt;p&gt;I HAVE READ THE PERMITTED DISCLOSURE FORM AND I UNDERSTAND IT.&lt;\/p&gt;  &lt;p&gt;I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.&lt;\/p&gt;  &lt;p&gt;I understand that uses and disclosures already made based upon my original permission cannot be taken back.&lt;\/p&gt;  &lt;p&gt;I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.&lt;\/p&gt;  &lt;p&gt;I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.&lt;\/p&gt;  &lt;p&gt;I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.&lt;\/p&gt;' class='gform_hidden' \/><input type='hidden' name='input_410.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_411\" 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_6_411'>Nombre completo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_411' id='input_6_411' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_412\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_412'>Fecha<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_412' id='input_6_412' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_412_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_412_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_412' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_413\" 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_413.1' id='input_6_413_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_6_413_1' >Acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_413.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_413.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_414\" 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_6_414'>Nombre completo del testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_414' id='input_6_414' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_415\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_415'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_415' id='input_6_415' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_415_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_415_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_415' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_416\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full 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<\/legend><div class='ginput_container ginput_container_consent'><input name='input_416.1' id='input_6_416_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_416_1' >Acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_416.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_416.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_417\" 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\"  ><strong>Por la presente autorizo a las siguientes personas a acceder a mi informaci\u00f3n m\u00e9dica en cualquier momento:<\/strong><\/div><div id=\"field_6_418\" 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_6_418'>Nombre del tutor\/representante<\/label><div class='ginput_container ginput_container_text'><input name='input_418' id='input_6_418' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_419\" 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_6_419'>Relaci\u00f3n Legal<\/label><div class='ginput_container ginput_container_text'><input name='input_419' id='input_6_419' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_420\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_420'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_420' id='input_6_420' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_420_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_420_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_420' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_421\" 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_6_421'>Testigo<\/label><div class='ginput_container ginput_container_text'><input name='input_421' id='input_6_421' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_422\" 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\"  ><strong>Por la presente autorizo a las siguientes personas a acceder a mi informaci\u00f3n m\u00e9dica en cualquier momento:<\/strong><\/div><div id=\"field_6_423\" 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_6_423'>Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_423' id='input_6_423' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_434\" 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_6_434'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_434' id='input_6_434' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_433\" 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_6_433'>N\u00famero de tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_433' id='input_6_433' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_435\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_435' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_435_1_container' >\n                                        <input type='text' name='input_435.1' id='input_6_435_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_435_1' id='input_6_435_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_435_2_container' >\n                                        <input type='text' name='input_435.2' id='input_6_435_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_435_2' id='input_6_435_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_435_3_container' >\n                                    <input type='text' name='input_435.3' id='input_6_435_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_435_3' id='input_6_435_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_435_4_container' >\n                                        <input type='text' name='input_435.4' id='input_6_435_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_435_4' id='input_6_435_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_435_5_container' >\n                                    <input type='text' name='input_435.5' id='input_6_435_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_435_5' id='input_6_435_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_435_6_container' >\n                                        <select name='input_435.6' id='input_6_435_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >Estados Unidos<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_6_435_6' id='input_6_435_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_439\" 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\"  ><br \/><\/div><div id=\"field_6_432\" 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_6_432'>Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_432' id='input_6_432' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_431\" 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_6_431'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_431' id='input_6_431' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_430\" 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_6_430'>N\u00famero de tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_430' id='input_6_430' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_438\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_438' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_438_1_container' >\n                                        <input type='text' name='input_438.1' id='input_6_438_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_438_1' id='input_6_438_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_438_2_container' >\n                                        <input type='text' name='input_438.2' id='input_6_438_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_438_2' id='input_6_438_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_438_3_container' >\n                                    <input type='text' name='input_438.3' id='input_6_438_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_438_3' id='input_6_438_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_438_4_container' >\n                                        <input type='text' name='input_438.4' id='input_6_438_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_438_4' id='input_6_438_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_438_5_container' >\n                                    <input type='text' name='input_438.5' id='input_6_438_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_438_5' id='input_6_438_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_438_6_container' >\n                                        <select name='input_438.6' id='input_6_438_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >Estados Unidos<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_6_438_6' id='input_6_438_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_442\" 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\"  ><br \/><\/div><div id=\"field_6_429\" 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_6_429'>Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_429' id='input_6_429' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_428\" 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_6_428'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_428' id='input_6_428' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_427\" 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_6_427'>N\u00famero de tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_427' id='input_6_427' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_437\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_437' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_437_1_container' >\n                                        <input type='text' name='input_437.1' id='input_6_437_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_437_1' id='input_6_437_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_437_2_container' >\n                                        <input type='text' name='input_437.2' id='input_6_437_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_437_2' id='input_6_437_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_437_3_container' >\n                                    <input type='text' name='input_437.3' id='input_6_437_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_437_3' id='input_6_437_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_437_4_container' >\n                                        <input type='text' name='input_437.4' id='input_6_437_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_437_4' id='input_6_437_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_437_5_container' >\n                                    <input type='text' name='input_437.5' id='input_6_437_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_437_5' id='input_6_437_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_437_6_container' >\n                                        <select name='input_437.6' id='input_6_437_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >Estados Unidos<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_6_437_6' id='input_6_437_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_441\" 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\"  ><br \/><\/div><div id=\"field_6_426\" 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_6_426'>Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_426' id='input_6_426' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_425\" 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_6_425'>Relaci\u00f3n<\/label><div class='ginput_container ginput_container_text'><input name='input_425' id='input_6_425' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_424\" 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_6_424'>N\u00famero de tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_424' id='input_6_424' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_436\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_6_436' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_436_1_container' >\n                                        <input type='text' name='input_436.1' id='input_6_436_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_436_1' id='input_6_436_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_6_436_2_container' >\n                                        <input type='text' name='input_436.2' id='input_6_436_2' value=''     aria-required='false'   \/>\n                                        <label for='input_6_436_2' id='input_6_436_2_label' class='gform-field-label gform-field-label--type-sub'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_436_3_container' >\n                                    <input type='text' name='input_436.3' id='input_6_436_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_436_3' id='input_6_436_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_436_4_container' >\n                                        <input type='text' name='input_436.4' id='input_6_436_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_436_4' id='input_6_436_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_436_5_container' >\n                                    <input type='text' name='input_436.5' id='input_6_436_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_436_5' id='input_6_436_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_6_436_6_container' >\n                                        <select name='input_436.6' id='input_6_436_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >Estados Unidos<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_6_436_6' id='input_6_436_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_440\" 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\"  ><br \/><\/div><fieldset id=\"field_6_443\" 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_443.1' id='input_6_443_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_6_443_1' >Acepto firmar electr\u00f3nicamente.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_443.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_443.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_446\" 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_6_446'>Firma del paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_446' id='input_6_446' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_447\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_447'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_447' id='input_6_447' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_447_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_447_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_447' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_6_444\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full 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<\/legend><div class='ginput_container ginput_container_consent'><input name='input_444.1' id='input_6_444_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_444_1' >Acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_444.2' value='I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_444.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_445\" 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_6_445'>Firma de un Testigo:<\/label><div class='ginput_container ginput_container_text'><input name='input_445' id='input_6_445' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_448\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_6_448'>Fecha<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_448' id='input_6_448' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_448_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_448_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_448' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_408' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_408' 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_6_11' class='gform_page' data-js='page-field-id-408' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_409\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full pagebreak gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><pagebreak\/>\n<h3 style=\"text-decoration: underline;\">Formulario de Divulgaci\u00f3n de Registros M\u00e9dicos<\/h3>\n<\/div><div id=\"field_6_291\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_291'>Nombre del paciente<\/label><div class='ginput_container ginput_container_text'><input name='input_291' id='input_6_291' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_292\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_292'>Fecha de nacimiento<\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_6_292' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_293\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_293'>Tel\u00e9fono<\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_6_293' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_294\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_294' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_294_1_container' >\n                                        <input type='text' name='input_294.1' id='input_6_294_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_294_1' id='input_6_294_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_294_3_container' >\n                                    <input type='text' name='input_294.3' id='input_6_294_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_294_3' id='input_6_294_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_294_4_container' >\n                                        <input type='text' name='input_294.4' id='input_6_294_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_294_4' id='input_6_294_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_294_5_container' >\n                                    <input type='text' name='input_294.5' id='input_6_294_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_294_5' id='input_6_294_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_294.6' id='input_6_294_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_6_295\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>1. Autorizo el uso o divulgaci\u00f3n de la informaci\u00f3n m\u00e9dica de la persona mencionada anteriormente como se describe a continuaci\u00f3n:<\/strong><\/p>\n<p><strong>2. La siguiente persona u organizaci\u00f3n est\u00e1 autorizada para hacer la divulgaci\u00f3n: <\/strong><\/p><\/div><div id=\"field_6_296\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_296'>Nombre<\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_6_296' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_297\" class=\"gfield gfield--type-address gfield--input-type-address 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' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_6_297' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_297_1_container' >\n                                        <input type='text' name='input_297.1' id='input_6_297_1' value=''    aria-required='false'    \/>\n                                        <label for='input_6_297_1' id='input_6_297_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_6_297_3_container' >\n                                    <input type='text' name='input_297.3' id='input_6_297_3' value=''    aria-required='false'    \/>\n                                    <label for='input_6_297_3' id='input_6_297_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_6_297_4_container' >\n                                        <input type='text' name='input_297.4' id='input_6_297_4' value=''      aria-required='false'    \/>\n                                        <label for='input_6_297_4' id='input_6_297_4_label' class='gform-field-label gform-field-label--type-sub'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_6_297_5_container' >\n                                    <input type='text' name='input_297.5' id='input_6_297_5' value=''    aria-required='false'    \/>\n                                    <label for='input_6_297_5' id='input_6_297_5_label' class='gform-field-label gform-field-label--type-sub'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_297.6' id='input_6_297_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_6_298\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox 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' >3. El tipo y la cantidad de informaci\u00f3n que se utilizar\u00e1 o divulgar\u00e1 es la siguiente: (incluya las fechas cuando corresponda).<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_6_298'><div class='gchoice gchoice_6_298_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.1' type='checkbox'  value='All medical records'  id='choice_6_298_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_1' id='label_6_298_1' class='gform-field-label gform-field-label--type-inline'>Todos los registros m\u00e9dicos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.2' type='checkbox'  value='Consultation Reports'  id='choice_6_298_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_2' id='label_6_298_2' class='gform-field-label gform-field-label--type-inline'>Informes de consulta<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.3' type='checkbox'  value='Dosimetry \/ Physics'  id='choice_6_298_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_3' id='label_6_298_3' class='gform-field-label gform-field-label--type-inline'>Dosimetr\u00eda \/ F\u00edsica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.4' type='checkbox'  value='Lab results\/X\u2010ray reports'  id='choice_6_298_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_4' id='label_6_298_4' class='gform-field-label gform-field-label--type-inline'>Resultados de laboratorio\/Informes de rayos X<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.5' type='checkbox'  value='Progress Notes'  id='choice_6_298_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_5' id='label_6_298_5' class='gform-field-label gform-field-label--type-inline'>Notas de progreso<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.6' type='checkbox'  value='Follow up'  id='choice_6_298_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_6' id='label_6_298_6' class='gform-field-label gform-field-label--type-inline'>Seguimiento<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_298_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_298.7' type='checkbox'  value='Other (Please specify)'  id='choice_6_298_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_298_7' id='label_6_298_7' class='gform-field-label gform-field-label--type-inline'>Otros (especifique)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_300\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>4. Entiendo que la informaci\u00f3n en mis registros m\u00e9dicos puede incluir informaci\u00f3n relacionada con enfermedades de transmisi\u00f3n sexual, s\u00edndrome de inmunodeficiencia adquirida (SIDA) o virus de inmunodeficiencia humana (VIH). Tambi\u00e9n puede incluir informaci\u00f3n sobre servicios de salud mental o temperamental y tratamiento para el abuso de alcohol y drogas.<\/strong><\/p> \n\n<p><strong>5. Esta informaci\u00f3n puede ser divulgada y utilizada por la siguiente persona u organizaci\u00f3n.<\/strong><\/p><\/div><fieldset id=\"field_6_368\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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' >Ubicaci\u00f3n | Advocate Radiation Oncology LLC<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_6_368'>\n\t\t\t<div class='gchoice gchoice_6_368_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Port Charlotte&lt;\/strong&gt; &lt;br&gt;3080 Harbor Blvd. &lt;br&gt;Port Charlotte, FL 33952 &lt;br&gt;Phone: (941) 883-2199 &lt;br&gt;Fax: (941) 979-5041'  id='choice_6_368_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_0' id='label_6_368_0' class='gform-field-label gform-field-label--type-inline'><strong>Port Charlotte<\/strong> <br>3080 Harbor Blvd. <br>Port Charlotte, FL 33952 <br>Tel\u00e9fono: (941) 883-2199 <br>Fax: (941) 979-5041<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Port Charlotte 2&lt;\/strong&gt; &lt;br&gt;3175 Harbor Blvd&lt;br&gt;Port Charlotte, FL 33952 &lt;br&gt;Phone: (941) 220-6460 &lt;br&gt;Fax: (941) 220-5284'  id='choice_6_368_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_1' id='label_6_368_1' class='gform-field-label gform-field-label--type-inline'><strong>Port Charlotte 2<\/strong> <br>3175 Harbor Blvd<br>Port Charlotte, FL 33952 <br>Phone: (941) 220-6460 <br>Fax: (941) 220-5284<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Fort Myers&lt;\/strong&gt; &lt;br&gt;15681 New Hampshire Ct. &lt;br&gt;Fort Myers, FL 33908 &lt;br&gt;Phone: (239) 437-1977 &lt;br&gt;Fax: (239) 437-1889'  id='choice_6_368_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_2' id='label_6_368_2' class='gform-field-label gform-field-label--type-inline'><strong>Fort Myers<\/strong> <br>15681 New Hampshire Ct. <br>Fort Myers, FL 33908 <br>Tel\u00e9fono: (239) 437-1977 <br>Fax: (239) 437-1889<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Cape Coral&lt;\/strong&gt; &lt;br&gt;909 Del Pra do Blvd. S &lt;br&gt;Cape Coral, FL 33990 &lt;br&gt;Phone: (239) 217-8070 &lt;br&gt;Fax: (239) 217-8069'  id='choice_6_368_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_3' id='label_6_368_3' class='gform-field-label gform-field-label--type-inline'><strong>Cape Coral<\/strong> <br>909 Del Prado Blvd. S <br>Cape Coral, FL 33990 <br>Tel\u00e9fono: (239) 217-8070 <br>Fax: (239) 217-8069<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Bonita Springs&lt;\/strong&gt; &lt;br&gt;25243 Elementary Way&lt;br&gt;Bonita Spings, FL 34135 &lt;br&gt;Phone: (239) 317-2772 &lt;br&gt;Fax: (239) 676-7637'  id='choice_6_368_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_4' id='label_6_368_4' class='gform-field-label gform-field-label--type-inline'><strong>Bonita Springs<\/strong> <br>25243 Elementary Way<br>Bonita Spings, FL 34135 <br>Tel\u00e9fono: (239) 317-2772 <br>Fax: (239) 676-7637<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Naples&lt;\/strong&gt; &lt;br&gt;1775 Davis Blvd. &lt;br&gt;Naples, FL 34102 &lt;br&gt;Phone: (239) 372-2838'  id='choice_6_368_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_5' id='label_6_368_5' class='gform-field-label gform-field-label--type-inline'><strong>Naples<\/strong> <br>1775 Davis Blvd. <br>Naples, FL 34102 <br>Tel\u00e9fono: (239) 372-2838<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Bradenton&lt;\/strong&gt; &lt;br&gt;5325 E St Road 64&lt;br&gt;Bradenton, FL 34208 &lt;br&gt;Phone: (941) 220-6263 &lt;br&gt;Fax: (386) 490-9100'  id='choice_6_368_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_6' id='label_6_368_6' class='gform-field-label gform-field-label--type-inline'><strong>Bradenton<\/strong> <br>5325 E St Road 64<br>Bradenton, FL 34208 <br>Tel\u00e9fono: (941) 220-6263 <br>Fax: (386) 490-9100<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Tamarac&lt;\/strong&gt; &lt;br&gt;7850 N. University Drive&lt;br&gt;Tamarac, FL 33321 &lt;br&gt;Phone: (754) 205-0099 &lt;br&gt;Fax: (954) 388-5849'  id='choice_6_368_7' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_7' id='label_6_368_7' class='gform-field-label gform-field-label--type-inline'><strong>Tamarac<\/strong> <br>7850 N. University Drive<br>Tamarac, FL 33321 <br>Tel\u00e9fono: (754) 205-0099 <br>Fax: (954) 388-5849<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_8'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;West Palm Beach&lt;\/strong&gt; &lt;br&gt;4832 Okeechobee Blvd&lt;br&gt;West Palm Beach, FL 33417 &lt;br&gt;Phone: (561) 277-0786 &lt;br&gt;Fax: (561) 277-0831'  id='choice_6_368_8' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_8' id='label_6_368_8' class='gform-field-label gform-field-label--type-inline'><strong>West Palm Beach<\/strong> <br>4832 Okeechobee Blvd.<br>West Palm Beach, FL 33417 <br>Tel\u00e9fono: (561) 277-0786 <br>Fax: (561) 277-0831<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_9'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Wellen Park - Venice&lt;\/strong&gt; &lt;br&gt; 8020 S Tamiami Trail Suite 101 &lt;br&gt;Venice, FL 34293 &lt;br&gt;Phone: (941) 220-6460 &lt;br&gt;Fax: (941) 220-5284'  id='choice_6_368_9' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_9' id='label_6_368_9' class='gform-field-label gform-field-label--type-inline'><strong>Wellen Park - Venice<\/strong> <br> 8020 S Tamiami Trail Suite 101 <br>Venice, FL 34293 <br>Phone: (941) 220-6460 <br>Fax: (941) 220-5284<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_10'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Proton Center&lt;\/strong&gt; &lt;br&gt;9961 Estero Oaks Dr, 1st Floor &lt;br&gt;Fort Myers, FL 33967'  id='choice_6_368_10' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_10' id='label_6_368_10' class='gform-field-label gform-field-label--type-inline'><strong>Proton Center<\/strong> <br>9961 Estero Oaks Dr, 1st Floor <br>Fort Myers, FL 33967<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_368_11'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_368' type='radio' value='&lt;strong&gt;Lakewood Ranch&lt;\/strong&gt; &lt;br&gt;8946 77th Terrace East&lt;br&gt;Lakewood Ranch, FL, 34202-6421'  id='choice_6_368_11' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_368_11' id='label_6_368_11' class='gform-field-label gform-field-label--type-inline'><strong>Lakewood Ranch<\/strong> <br>8946 77th Terrace East<br>Lakewood Ranch, FL, 34202-6421<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_302\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_302'>Con el prop\u00f3sito de:<\/label><div class='ginput_container ginput_container_text'><input name='input_302' id='input_6_302' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_303\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_303'>6. Entiendo que tengo derecho a revocar esta autorizaci\u00f3n en cualquier momento. Entiendo que si revoco esta autorizaci\u00f3n debo hacerlo por escrito y presentar mi revocaci\u00f3n por escrito al departamento de administraci\u00f3n de informaci\u00f3n m\u00e9dica. Entiendo que la revocaci\u00f3n no se aplicar\u00e1 a mi compa\u00f1\u00eda de seguros cuando la ley le otorgue a mi aseguradora el derecho a impugnar un reclamo bajo mi p\u00f3liza. A menos que se revoque de otra manera, esta autorizaci\u00f3n vencer\u00e1 en la siguiente fecha, evento o condici\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_6_303' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_305\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>7. Si no especifico una fecha de vencimiento, evento o condici\u00f3n, esta autorizaci\u00f3n vencer\u00e1 en un a\u00f1o. Entiendo que autorizar la divulgaci\u00f3n de esta informaci\u00f3n m\u00e9dica es voluntario. Puedo negarme a firmar esta autorizaci\u00f3n. No necesito firmar este formulario para asegurar el tratamiento. Entiendo que puedo inspeccionar o copiar la informaci\u00f3n que se utilizar\u00e1 o divulgar\u00e1, seg\u00fan lo dispuesto en CFR 164.524. Entiendo que cualquier divulgaci\u00f3n de informaci\u00f3n conlleva la posibilidad de una nueva divulgaci\u00f3n no autorizada y es posible que la informaci\u00f3n no est\u00e9 protegida por las reglas federales de confidencialidad. Si tengo preguntas sobre la divulgaci\u00f3n de mi informaci\u00f3n m\u00e9dica, puedo contactar a un representante de la cl\u00ednica en cualquiera de las oficinas de Advocate Radiation Oncology.<\/strong><\/p><\/div><fieldset id=\"field_6_347\" 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 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_347.1' id='input_6_347_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_6_347_1' >S\u00ed, acepto firmar electr\u00f3nicamente.<\/label><input type='hidden' name='input_347.2' value='Yes, I agree to sign electronically.' class='gform_hidden' \/><input type='hidden' name='input_347.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_306\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half 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_6_306'>Firma del paciente o del representante legal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_306' id='input_6_306' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_309\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_third 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_6_309'>Fecha<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_309' id='input_6_309' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_309_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_309_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_309' class='gform_hidden' value='https:\/\/register.advocatero.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_6_307\" class=\"gfield gfield--type-text gfield--input-type-text 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_6_307'>Nombre impreso del representante y relaci\u00f3n con el paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_307' id='input_6_307' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_387' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='button' id='gform_next_button_6_387' 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_6_12' class='gform_page' data-js='page-field-id-387' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_388\" 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\"  >Por favor, revise cuidadosamente su presentaci\u00f3n. Si hay alg\u00fan error, utilice los enlaces anteriores para editar esa secci\u00f3n. <br \/><br \/>\n\n<strong>On page 10, you selected this as your primary office location:<\/strong><br \/><br \/>\n<span style=\"color: #ff0000;\">{Campo:368}<\/span>\n\n<br \/><br \/>\n\n{todos_los_campos}<\/div><div id=\"field_6_390\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_390'>N\u00famero de confirmaci\u00f3n (interno)<\/label><div class='ginput_container ginput_container_text'><input name='input_390' id='input_6_390' type='text' value='' class=''      aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anteriormente'  \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_6' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_6' id='gform_theme_6' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_6' id='gform_style_settings_6' value='[]' \/>\n            <input 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