{"id":120,"date":"2026-09-15T18:59:52","date_gmt":"2026-09-15T18:59:52","guid":{"rendered":"https:\/\/mannheimdental.com\/?page_id=120"},"modified":"2026-10-04T00:02:04","modified_gmt":"2026-10-04T00:02:04","slug":"book-now","status":"publish","type":"page","link":"https:\/\/mannheimdental.com\/es\/book-now\/","title":{"rendered":"AGENDAR CITA"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"120\" class=\"elementor elementor-120\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-cfd604f e-con e-atomic-element e-flexbox-base e-default-div e-5a5ae80 \" data-id=\"cfd604f\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"cfd604f\" data-e-type=\"e-flexbox\" data-id=\"cfd604f\">\n    <div class=\"elementor-element elementor-element-bae6c3e e-con e-atomic-element e-flexbox-base e-default-div e-1769c94 \" data-id=\"bae6c3e\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"bae6c3e\" data-e-type=\"e-flexbox\" data-id=\"bae6c3e\">\n    \n<\/div>\n<div class=\"elementor-element elementor-element-549d610 e-con e-atomic-element e-flexbox-base e-default-div e-598ccd7 \" data-id=\"549d610\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"549d610\" data-e-type=\"e-flexbox\" data-id=\"549d610\">\n    \t\t<div class=\"elementor-element elementor-element-05c888a elementor-widget elementor-widget-heading\" data-id=\"05c888a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Request an appointment<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-b25e513 elementor-widget elementor-widget-text-editor\" data-id=\"b25e513\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Fill out the quick form below and our team will confirm your appointment by phone. New patients always welcome.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-8738267 e-con e-atomic-element e-flexbox-base e-default-div e-6bd2928 \" data-id=\"8738267\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"8738267\" data-e-type=\"e-flexbox\" data-id=\"8738267\">\n    \n<\/div>\n\n<\/div>\n<div class=\"elementor-element elementor-element-b040fcf e-con e-atomic-element e-flexbox-base e-default-div e-b040fcf-430d708 \" data-id=\"b040fcf\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"b040fcf\" data-e-type=\"e-flexbox\" data-id=\"b040fcf\">\n    <div class=\"elementor-element elementor-element-d1eda5e e-con e-atomic-element e-flexbox-base e-default-div e-d1eda5e-2f008ac \" data-id=\"d1eda5e\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"d1eda5e\" data-e-type=\"e-flexbox\" data-id=\"d1eda5e\">\n    \n<\/div>\n<div class=\"elementor-element elementor-element-996cf3e e-con e-atomic-element e-flexbox-base e-default-div e-996cf3e-bec89f9 \" data-id=\"996cf3e\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"996cf3e\" data-e-type=\"e-flexbox\" data-id=\"996cf3e\">\n    \t\t<div class=\"elementor-element elementor-element-cd2dba2 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"cd2dba2\" data-element_type=\"widget\" data-e-type=\"widget\" data-no-translation=\"\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t\t\t\t\t<div class=\"eael-contact-form eael-gravity-form title-description-hide eael-custom-radio-checkbox eael-contact-form-align-default\">\n\t\t        \t\t\t\t\t<div class=\"eael-gravity-form-heading\">\n\t\t\t\t        \t\t\t\t        \t\t\t\t\t<\/div>\n\t\t        \n            <script type=\"text\/javascript\">\n                \/* EA Gravity Forms - fallback dispatch of GF's per-form post-render event.\n                 *\n                 * GF normally dispatches this itself from GFFormDisplay::footer_init_scripts().\n                 * In render contexts where that never runs, GF add-ons that bind to\n                 * `gform\/post_render` - e.g. the reCAPTCHA Add-On v2.2.2+, which registers its\n                 * v3 token submission filter there - are never initialised.\n                 *\n                 * Dispatching unconditionally is not safe. GF's multi-file uploader calls\n                 * `new plupload.Uploader()` on every post_render with no idempotency guard\n                 * (gravityforms\/js\/gravityforms.js), so a second dispatch binds a second\n                 * uploader to the same field and every selected file is submitted twice. GF's\n                 * own guard is function-local to the script it prints and cannot be read from\n                 * here, so we watch for the event instead and only step in if it never comes.\n                 *\n                 * This is the single fallback for this widget. Tickets 84410 and 84529 each\n                 * added one independently and both were merged, leaving two mutually-blind\n                 * shims that raced (issue #894). Do not add another - extend this one, and\n                 * keep the `window.__eaelGfPostRender*` flags as the shared source of truth.\n                 *\n                 * Printed before the form markup so the listeners are in place ahead of any\n                 * GF init script for this form, whether printed inline or in the footer.\n                 *\/\n                ( function () {\n                    var formId    = 2;\n                    var seenFlag  = '__eaelGfPostRenderSeen_'  + formId; \/\/ dispatched, by anyone\n                    var boundFlag = '__eaelGfPostRenderBound_' + formId; \/\/ this shim is installed\n\n                    if ( window[ boundFlag ] ) {\n                        return;\n                    }\n                    window[ boundFlag ] = true;\n\n                    function markSeen( id ) {\n                        if ( parseInt( id, 10 ) === formId ) {\n                            window[ seenFlag ] = true;\n                        }\n                    }\n\n                    \/\/ triggerPostRenderEvents() always fires the jQuery event first and the\n                    \/\/ gform.utils one after, whoever calls it - so between them these observe\n                    \/\/ GF core's own dispatch as well as any other caller's.\n                    if ( window.jQuery ) {\n                        window.jQuery( document ).on( 'gform_post_render', function ( event, id ) {\n                            markSeen( typeof id !== 'undefined' ? id : formId );\n                        } );\n                    }\n                    if ( window.gform && window.gform.utils\n                         && typeof window.gform.utils.addEventListener === 'function' ) {\n                        window.gform.utils.addEventListener( 'gform\/post_render', function ( e ) {\n                            markSeen( e && e.detail && typeof e.detail.formId !== 'undefined'\n                                      ? e.detail.formId : formId );\n                        } );\n                    }\n\n                    function maybeDispatch() {\n                        if ( window[ seenFlag ] ) {\n                            return;\n                        }\n\n                        \/\/ GF leaves this marker beside a hidden form while it waits for the\n                        \/\/ form to become visible, and removes it once it dispatches. Still\n                        \/\/ present means GF's script did run and will dispatch on its own -\n                        \/\/ firing now is the double-dispatch that duplicates file uploads.\n                        if ( document.getElementById( 'gform_visibility_test_' + formId ) ) {\n                            return;\n                        }\n\n                        if ( ! window.gform || ! window.gform.core\n                             || typeof window.gform.core.triggerPostRenderEvents !== 'function' ) {\n                            return;\n                        }\n\n                        var pageInput   = document.getElementById( 'gform_source_page_number_' + formId );\n                        var currentPage = pageInput ? parseInt( pageInput.value, 10 ) : 1;\n\n                        window[ seenFlag ] = true;\n                        window.gform.core.triggerPostRenderEvents( formId, currentPage || 1 );\n                    }\n\n                    \/\/ Wait for the window load event and then for GF's own gate, which needs\n                    \/\/ DOMContentLoaded plus its main and theme script events. Registering the\n                    \/\/ callback this late puts it behind GF's in the queue, and the timeout\n                    \/\/ puts it in a later task again, so GF always gets to dispatch first.\n                    function schedule() {\n                        if ( window.gform && typeof window.gform.initializeOnLoaded === 'function' ) {\n                            window.gform.initializeOnLoaded( function () {\n                                setTimeout( maybeDispatch, 0 );\n                            } );\n                        } else {\n                            setTimeout( maybeDispatch, 0 );\n                        }\n                    }\n\n                    if ( document.readyState === 'complete' ) {\n                        schedule();\n                    } else {\n                        window.addEventListener( 'load', schedule );\n                    }\n                } )();\n            <\/script>\n\n            <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 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-btn-bg-color-hover-tertiary: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/es\/wp-json\/wp\/v2\/pages\/120' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_above description_above validation_above'><div id=\"field_2_86\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_86'><span class='gform-field-label__text'>Comments<\/span><\/label><div class='gfield_description' id='gfield_description_2_86'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div><div class='ginput_container'><input name='input_86' id='input_2_86' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'><span class='gform-field-label__text'>NOMBRES COMPLETOS<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_1'><span class='gform-field-label__text'>APELLIDOS<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_2_1' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'><span class='gform-field-label__text'>CORREO ELECTRONICO<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_2_11' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_17'><span class='gform-field-label__text'>TELEFONO DE CELULAR<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_17' id='input_2_17' type='tel' value='' class='large'  placeholder='(999) 999-9999' aria-required=\"true\" aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'><span class='gform-field-label__text'>FECHA PREFERIDA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='10\/19\/2026'\n\t\t\t\t\tid='input_2_19'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_19'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_19' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_19' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_19' aria-label='FECHA PREFERIDA: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_2_83\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_83'><span class='gform-field-label__text'>HORA PREFERIDA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_2_83' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Ma\u00f1ana (9:00 AM \u2013 12:00 PM) \u2013 mar., vie., s\u00e1b.' >Ma\u00f1ana (9:00 AM \u2013 12:00 PM) \u2013 mar., vie., s\u00e1b.<\/option><option value='Mediod\u00eda (11:00 AM \u2013 2:00 PM) \u2013 lun. a s\u00e1b.' >Mediod\u00eda (11:00 AM \u2013 2:00 PM) \u2013 lun. a s\u00e1b.<\/option><option value='Tarde (2:00 PM \u2013 6:00 PM) \u2013 lun. y mi\u00e9.' >Tarde (2:00 PM \u2013 6:00 PM) \u2013 lun. y mi\u00e9.<\/option><option value='Sin preferencia' >Sin preferencia<\/option><\/select><\/div><\/div><div id=\"field_2_85\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_85'><span class='gform-field-label__text'>MOTIVO DE LA CONSULTA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_2_85' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_2_18\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>TIPO DE PACIENTE<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_18'>\n\t\t\t<div class='gchoice gchoice_2_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='NUEVO PACIENTE'  id='choice_2_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_0' id='label_2_18_0' class='gform-field-label gform-field-label--type-inline'>NUEVO PACIENTE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='PACIENTE EXISTENTE'  id='choice_2_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_18_1' id='label_2_18_1' class='gform-field-label gform-field-label--type-inline'>PACIENTE EXISTENTE<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_84\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">INFORMACION ADICIONAL DEL PACIENTE<\/h3><\/div><fieldset id=\"field_2_12\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>DIRECCION<\/span><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_2_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_12_1_container' >\n                                        <label for='input_2_12_1' id='input_2_12_1_label' class='gform-field-label gform-field-label--type-sub '>DOMICILIO<\/label>\n                                        <input type='text' name='input_12.1' id='input_2_12_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_12_3_container' >\n                                    <label for='input_2_12_3' id='input_2_12_3_label' class='gform-field-label gform-field-label--type-sub '>CIUDAD<\/label>\n                                    <input type='text' name='input_12.3' id='input_2_12_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_12_4_container' >\n                                        <label for='input_2_12_4' id='input_2_12_4_label' class='gform-field-label gform-field-label--type-sub '>ESTADO<\/label>\n                                        <input type='text' name='input_12.4' id='input_2_12_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_12_5_container' >\n                                    <label for='input_2_12_5' id='input_2_12_5_label' class='gform-field-label gform-field-label--type-sub '>CODIGO POSTAL<\/label>\n                                    <input type='text' name='input_12.5' id='input_2_12_5' value=''    aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_2_12_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_2_13\" 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_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_13'><span class='gform-field-label__text'>FECHA DE NACIMIENTO<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='mm\/dd\/aaaa'\n\t\t\t\t\tid='input_2_13'\n\t\t\t\t\tclass='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_13'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_2_13' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_2_13' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_2_13' aria-label='FECHA DE NACIMIENTO: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'><span class='gform-field-label__text'>GENERO<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_2_14' class='large gfield_select'     aria-invalid=\"false\" ><option value='MASCULINO' >MASCULINO<\/option><option value='FEMENINO' >FEMENINO<\/option><option value='NO DEFINIDO' >NO DEFINIDO<\/option><option value='OTRO' >OTRO<\/option><\/select><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'><span class='gform-field-label__text'>\u00bfQu\u00e9 pronombres utiliza?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_2_15' class='large gfield_select'     aria-invalid=\"false\" ><option value='\u00c9l' >\u00c9l<\/option><option value='Ella' >Ella<\/option><option value='Elle' >Elle<\/option><option value='Prefiero no responder' >Prefiero no responder<\/option><option value='Otro' >Otro<\/option><\/select><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'><span class='gform-field-label__text'>ESTADO CIVIL<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_2_16' class='large gfield_select'     aria-invalid=\"false\" ><option value='CASADO (A)' >CASADO (A)<\/option><option value='SOLTERO (A)' >SOLTERO (A)<\/option><\/select><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'><span class='gform-field-label__text'>TELEFONO DE CASA<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_24' id='input_2_24' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_25'><span class='gform-field-label__text'>TELEFONO DEL TRABAJO<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_2_25' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_23\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_23'><span class='gform-field-label__text'>NUMERO DE SEGURO SOCIAL<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_23' id='input_2_23' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_2_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEL PACIENTE ES MENOR DE EDAD?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_26'>\n\t\t\t<div class='gchoice gchoice_2_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='SI'  id='choice_2_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_0' id='label_2_26_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_2_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='NO'  id='choice_2_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_26_1' id='label_2_26_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_2_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SI EL PACIENTE ES MENOR DE EDAD,PROPORCIONE LO SIGUIENTE<\/h3><\/div><div id=\"field_2_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_29'><span class='gform-field-label__text'>NOMBRE DE PADRE\/MADE O TUTOR<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_2_29' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_30\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_30'><span class='gform-field-label__text'>RELACION<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_2_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='PADRES' >PADRES<\/option><option value='ABUELOS' >ABUELOS<\/option><option value='OTRO' >OTRO<\/option><option value='TUTOR LEGAL' >TUTOR LEGAL<\/option><\/select><\/div><\/div><fieldset id=\"field_2_31\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>DIRECCION<\/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_2_31' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_2_31_1_container' >\n                                        <label for='input_2_31_1' id='input_2_31_1_label' class='gform-field-label gform-field-label--type-sub '>DOMICILIO<\/label>\n                                        <input type='text' name='input_31.1' id='input_2_31_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_2_31_3_container' >\n                                    <label for='input_2_31_3' id='input_2_31_3_label' class='gform-field-label gform-field-label--type-sub '>CIUDAD<\/label>\n                                    <input type='text' name='input_31.3' id='input_2_31_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_2_31_4_container' >\n                                        <label for='input_2_31_4' id='input_2_31_4_label' class='gform-field-label gform-field-label--type-sub '>ESTADO<\/label>\n                                        <input type='text' name='input_31.4' id='input_2_31_4' value=''      aria-required='false'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_2_31_5_container' >\n                                    <label for='input_2_31_5' id='input_2_31_5_label' class='gform-field-label gform-field-label--type-sub '>CODIGO POSTAL<\/label>\n                                    <input type='text' name='input_31.5' id='input_2_31_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_31.6' id='input_2_31_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_2_34\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-formatted gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>TELEFONO CELULAR<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_phone'>\n\t\t\t<div class=\"gform-phone gform-phone--show-dial-code\" role=\"application\">\n\t\t\t\t<div class=\"gform-phone__input-wrapper\">\n\t\t\t\t\t<span class=\"ginput_country-selector_container\">\n\t\t\t\t\t\t<label for='country_selector_button_34' id='country_selector_button_34_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n\t\t\t\t\t\t<button type=\"button\" id=\"country_selector_button_34\" class=\"gform-phone__country-selector gform-theme-button gform-theme-button--tertiary\" aria-haspopup=\"listbox\" aria-expanded=\"false\" aria-controls=\"gform_phone_dropdown_6ad56b1b7ce28\" aria-label=\"Select country\" >\n\t\t\t\t\t\t\t<span class=\"gform-phone__flag-icon gform-phone__flag-icon--us\"><\/span>\n\t\t\t\t\t\t\t<span class=\"gform-phone__dial-code\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<span class=\"ginput_phone_container\">\n\t\t\t\t\t\t<label for='input_2_34_visible' id='input_2_34_visible_label' class='gform-field-label gform-field-label--type-sub '>N\u00ba de tel\u00e9fono<\/label>\n\t\t\t\t\t\t<input type=\"tel\" class=\"gform-phone__input\" id=\"input_2_34_visible\" name=\"\" autocomplete=\"tel\" value=\"\"   aria-required=\"true\" aria-invalid=\"false\"  >\n\t\t\t\t\t\t\n\t\t\t\t\t<\/span>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__dropdown gform-phone__dropdown--hidden\" role=\"listbox\" id=\"gform_phone_dropdown_6ad56b1b7ce28\" tabindex=\"-1\">\n\t\t\t\t\t<div class=\"gform-phone__search-wrapper\">\n\t\t\t\t\t\t<input type=\"text\" class=\"gform-phone__search\" placeholder=\"Search countries\" aria-label=\"Search for a country\" aria-controls=\"gform_phone_dropdown_6ad56b1b7ce28_list\">\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<ul class=\"gform-phone__country-list gform-ul-reset\" id=\"gform_phone_dropdown_6ad56b1b7ce28_list\" role=\"listbox\" aria-label=\"Country list\">\n\t\t\t\t\t\t<!-- Country items will be populated by JavaScript -->\n\t\t\t\t\t<\/ul>\n\t\t\t\t\t<div class=\"gform-phone__aria-live-search-status\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; margin: -1px; border: 0; padding: 0; overflow: hidden; clip: rect(0, 0, 0, 0); clip-path: inset(50%); white-space: nowrap;\"><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"gform-phone__aria-live\" aria-live=\"polite\" aria-atomic=\"true\" style=\"position: absolute; width: 1px; height: 1px; padding: 0; margin: -1px; overflow: hidden; clip: rect(0 0 0 0); clip-path: inset(50%); border: 0; white-space: nowrap;\"><\/div>\n\t\t\t<\/div><input name='input_34' id='input_2_34' type='hidden' value='' class='large' data-phone-format='formatted' data-default-country='us' data-show-country-code='true' aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/fieldset><div id=\"field_2_32\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'><span class='gform-field-label__text'>NUMERO DE CASA<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_2_32' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'><span class='gform-field-label__text'>TELEFONO DEL TRABAJO<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_2_33' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_39'><span class='gform-field-label__text'>NUMERO DE SEGURO SOCIAL<\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_2_39' type='text' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'><span class='gform-field-label__text'>\u00bfCON QUI\u00c9N VIVE EL MENOR?<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_36' id='input_2_36' class='large gfield_select'     aria-invalid=\"false\" ><option value='MADRE' >MADRE<\/option><option value='PADRE' >PADRE<\/option><option value='AMBOS' >AMBOS<\/option><option value='OTRO' >OTRO<\/option><\/select><\/div><\/div><div id=\"field_2_37\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">INFORMACION EN CASO DE EMERGENCIA<\/h3><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'><span class='gform-field-label__text'>PERSONA PARA CONTACTAR EN CASO DE EMERGENCIA<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'><span class='gform-field-label__text'>RELACION<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_40\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--phone-format-standard gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'><span class='gform-field-label__text'>NUMERO DE TELEFONO<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_40' id='input_2_40' type='tel' value='' class='large'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/div><div id=\"field_2_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HISTORIA MEDICA<\/h3><div class='gsection_description' id='gfield_description_2_42'>Las siguientes preguntas son para su beneficio y asegurar que cualquier tratamiento dental tendr\u00e1 en cuenta su estado de salud pasado y presente. AlgunasPreguntas pueden parecer ajenas a su condici\u00f3n dental, pero est\u00e1n todos asociados con el cuidado de la salud bucal. Por favor, conteste cada pregunta.<\/div><\/div><fieldset id=\"field_2_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa tomado alg\u00fan medicamento o f\u00e1rmaco durante los \u00faltimos dos a\u00f1os?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_43'>\n\t\t\t<div class='gchoice gchoice_2_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='S\u00ed'  id='choice_2_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_0' id='label_2_43_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_2_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='No'  id='choice_2_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_43_1' id='label_2_43_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma Actualmente alg\u00fan medicamento, f\u00e1rmaco, pastillas o remedios herbales, incluyendo dosis de aspirina?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_44'>\n\t\t\t<div class='gchoice gchoice_2_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='S\u00ed'  id='choice_2_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_0' id='label_2_44_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_2_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='No'  id='choice_2_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_44_1' id='label_2_44_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEs usted sensible o al\u00e9rgico a alguna substancia o medicamento?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_45'>\n\t\t\t<div class='gchoice gchoice_2_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='S\u00ed'  id='choice_2_45_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_0' id='label_2_45_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_2_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_2_45_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_45_1' id='label_2_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_46\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfAlguna vez ha tomado medicamentos con receta m\u00e9dica para la p\u00e9rdida de peso (pastillas de dieta)?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_46'>\n\t\t\t<div class='gchoice gchoice_2_46_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='S\u00ed'  id='choice_2_46_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_0' id='label_2_46_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_2_46_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_46' type='radio' value='No'  id='choice_2_46_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_46_1' id='label_2_46_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_48\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Alguna vez ha tomado f\u00e1rmacos para la osteoporosis o prevenci\u00f3n de tal, como Fosamax, Actonel, Boniva o alg\u00fan f\u00e1rmaco similar?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_48'>\n\t\t\t<div class='gchoice gchoice_2_48_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='S\u00ed'  id='choice_2_48_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_0' id='label_2_48_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_2_48_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_48' type='radio' value='No'  id='choice_2_48_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_48_1' id='label_2_48_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa estado hospitalizado en los \u00faltimos cinco a\u00f1os?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_49'>\n\t\t\t<div class='gchoice gchoice_2_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='S\u00ed'  id='choice_2_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_0' id='label_2_49_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_2_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='No'  id='choice_2_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_49_1' id='label_2_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfAlguna vez ha tenido una lesi\u00f3n grave en la cabeza o la boca?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_50'>\n\t\t\t<div class='gchoice gchoice_2_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='S\u00ed'  id='choice_2_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_50_0' id='label_2_50_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_2_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_2_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_50_1' id='label_2_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfLe han dicho alguna vez que tome un pre-medicamento antes del tratamiento dental?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_51'>\n\t\t\t<div class='gchoice gchoice_2_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='S\u00ed'  id='choice_2_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_51_0' id='label_2_51_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_2_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='No'  id='choice_2_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_51_1' id='label_2_51_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Hay algo m\u00e1s acerca de tener un tratamiento dental que usted quisiera saber?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_52'>\n\t\t\t<div class='gchoice gchoice_2_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='S\u00ed'  id='choice_2_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_0' id='label_2_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_2_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='No'  id='choice_2_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_52_1' id='label_2_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfHa bajado o subido m\u00e9s de 10 libras durante el a\u00f1o pasado?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_53'>\n\t\t\t<div class='gchoice gchoice_2_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='S\u00ed'  id='choice_2_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_53_0' id='label_2_53_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_2_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='No'  id='choice_2_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_53_1' id='label_2_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTiene o ha tenido alguna enfermedad, condici\u00f3n o problema que no se haya mencionado?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_54'>\n\t\t\t<div class='gchoice gchoice_2_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='S\u00ed'  id='choice_2_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_0' id='label_2_54_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_2_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_2_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_54_1' id='label_2_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Indique cu\u00e1l de las siguientes ha tenido, o tiene en la actualidad<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_2_56'><div class='gchoice gchoice_2_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='ALDS\/HLV Positivo'  id='choice_2_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_1' id='label_2_56_1' class='gform-field-label gform-field-label--type-inline'>ALDS\/HLV Positivo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.2' type='checkbox'  value='Diabetes'  id='choice_2_56_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_2' id='label_2_56_2' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.3' type='checkbox'  value='Prolapso de la v\u00e1lvula mitral'  id='choice_2_56_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_3' id='label_2_56_3' class='gform-field-label gform-field-label--type-inline'>Prolapso de la v\u00e1lvula mitral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.4' type='checkbox'  value='Anemia'  id='choice_2_56_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_4' id='label_2_56_4' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.5' type='checkbox'  value='Trastornos nerviosos'  id='choice_2_56_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_5' id='label_2_56_5' class='gform-field-label gform-field-label--type-inline'>Trastornos nerviosos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.6' type='checkbox'  value='Artritis\/Reumatismo'  id='choice_2_56_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_6' id='label_2_56_6' class='gform-field-label gform-field-label--type-inline'>Artritis\/Reumatismo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.7' type='checkbox'  value='Dificultad para tragar'  id='choice_2_56_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_7' id='label_2_56_7' class='gform-field-label gform-field-label--type-inline'>Dificultad para tragar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.8' type='checkbox'  value='Nerviosismo\/ansiedad'  id='choice_2_56_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_8' id='label_2_56_8' class='gform-field-label gform-field-label--type-inline'>Nerviosismo\/ansiedad<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.9' type='checkbox'  value='V\u00e1lvula cardiaca artificial\/marcapasos'  id='choice_2_56_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_9' id='label_2_56_9' class='gform-field-label gform-field-label--type-inline'>V\u00e1lvula cardiaca artificial\/marcapasos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.11' type='checkbox'  value='Adicci\u00f3n a las drogas'  id='choice_2_56_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_11' id='label_2_56_11' class='gform-field-label gform-field-label--type-inline'>Adicci\u00f3n a las drogas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.12' type='checkbox'  value='Trastornos neurol\u00f3gicos'  id='choice_2_56_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_12' id='label_2_56_12' class='gform-field-label gform-field-label--type-inline'>Trastornos neurol\u00f3gicos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.13' type='checkbox'  value='Articulaciones artificiales'  id='choice_2_56_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_13' id='label_2_56_13' class='gform-field-label gform-field-label--type-inline'>Articulaciones artificiales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.14' type='checkbox'  value='Enfisema'  id='choice_2_56_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_14' id='label_2_56_14' class='gform-field-label gform-field-label--type-inline'>Enfisema<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.15' type='checkbox'  value='Osteoporosis'  id='choice_2_56_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_15' id='label_2_56_15' class='gform-field-label gform-field-label--type-inline'>Osteoporosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.16' type='checkbox'  value='Pr\u00f3tesis artificial'  id='choice_2_56_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_16' id='label_2_56_16' class='gform-field-label gform-field-label--type-inline'>Pr\u00f3tesis artificial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.17' type='checkbox'  value='Epilepsia o convulsiones'  id='choice_2_56_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_17' id='label_2_56_17' class='gform-field-label gform-field-label--type-inline'>Epilepsia o convulsiones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.18' type='checkbox'  value='Atenci\u00f3n psiqui\u00e1trica\/psicol\u00f3gica'  id='choice_2_56_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_18' id='label_2_56_18' class='gform-field-label gform-field-label--type-inline'>Atenci\u00f3n psiqui\u00e1trica\/psicol\u00f3gica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.19' type='checkbox'  value='Asma'  id='choice_2_56_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_19' id='label_2_56_19' class='gform-field-label gform-field-label--type-inline'>Asma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.21' type='checkbox'  value='Sangrado excesivo'  id='choice_2_56_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_21' id='label_2_56_21' class='gform-field-label gform-field-label--type-inline'>Sangrado excesivo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.22' type='checkbox'  value='Radioterapia'  id='choice_2_56_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_22' id='label_2_56_22' class='gform-field-label gform-field-label--type-inline'>Radioterapia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.23' type='checkbox'  value='Enfermedad sangu\u00ednea'  id='choice_2_56_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_23' id='label_2_56_23' class='gform-field-label gform-field-label--type-inline'>Enfermedad sangu\u00ednea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.24' type='checkbox'  value='Desmayos o mareos fuertes'  id='choice_2_56_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_24' id='label_2_56_24' class='gform-field-label gform-field-label--type-inline'>Desmayos o mareos fuertes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.25' type='checkbox'  value='Fiebrereum\u00e1tica'  id='choice_2_56_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_25' id='label_2_56_25' class='gform-field-label gform-field-label--type-inline'>Fiebrereum\u00e1tica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.26' type='checkbox'  value='Transfusi\u00f3n de sangre'  id='choice_2_56_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_26' id='label_2_56_26' class='gform-field-label gform-field-label--type-inline'>Transfusi\u00f3n de sangre<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.27' type='checkbox'  value='Glaucoma'  id='choice_2_56_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_27' id='label_2_56_27' class='gform-field-label gform-field-label--type-inline'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.28' type='checkbox'  value='Fiebre escarlata'  id='choice_2_56_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_28' id='label_2_56_28' class='gform-field-label gform-field-label--type-inline'>Fiebre escarlata<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.29' type='checkbox'  value='Presenta moretones con facilidad'  id='choice_2_56_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_29' id='label_2_56_29' class='gform-field-label gform-field-label--type-inline'>Presenta moretones con facilidad<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.31' type='checkbox'  value='Fiebre del heno'  id='choice_2_56_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_31' id='label_2_56_31' class='gform-field-label gform-field-label--type-inline'>Fiebre del heno<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.32' type='checkbox'  value='Alergia'  id='choice_2_56_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_32' id='label_2_56_32' class='gform-field-label gform-field-label--type-inline'>Alergia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.33' type='checkbox'  value='Urticaria'  id='choice_2_56_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_33' id='label_2_56_33' class='gform-field-label gform-field-label--type-inline'>Urticaria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.34' type='checkbox'  value='Cancer'  id='choice_2_56_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_34' id='label_2_56_34' class='gform-field-label gform-field-label--type-inline'>Cancer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.35' type='checkbox'  value='Tumores'  id='choice_2_56_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_35' id='label_2_56_35' class='gform-field-label gform-field-label--type-inline'>Tumores<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.36' type='checkbox'  value='Quistes'  id='choice_2_56_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_36' id='label_2_56_36' class='gform-field-label gform-field-label--type-inline'>Quistes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.37' type='checkbox'  value='Lesiones en la cabeza'  id='choice_2_56_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_37' id='label_2_56_37' class='gform-field-label gform-field-label--type-inline'>Lesiones en la cabeza<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.38' type='checkbox'  value='Sinusitis'  id='choice_2_56_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_38' id='label_2_56_38' class='gform-field-label gform-field-label--type-inline'>Sinusitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.39' type='checkbox'  value='Par\u00e1lisis cerebral'  id='choice_2_56_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_39' id='label_2_56_39' class='gform-field-label gform-field-label--type-inline'>Par\u00e1lisis cerebral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.41' type='checkbox'  value='Ataque al coraz\u00f3n'  id='choice_2_56_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_41' id='label_2_56_41' class='gform-field-label gform-field-label--type-inline'>Ataque al coraz\u00f3n<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.42' type='checkbox'  value='Quimioterapia'  id='choice_2_56_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_42' id='label_2_56_42' class='gform-field-label gform-field-label--type-inline'>Quimioterapia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.43' type='checkbox'  value='Insuficiencia cardiaca'  id='choice_2_56_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_43' id='label_2_56_43' class='gform-field-label gform-field-label--type-inline'>Insuficiencia cardiaca<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.44' type='checkbox'  value='Hinchaz\u00f3n de tobillos'  id='choice_2_56_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_44' id='label_2_56_44' class='gform-field-label gform-field-label--type-inline'>Hinchaz\u00f3n de tobillos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.45' type='checkbox'  value='Dolor de pecho'  id='choice_2_56_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_45' id='label_2_56_45' 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_2_56_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.46' type='checkbox'  value='Soplo cardiaco'  id='choice_2_56_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_46' id='label_2_56_46' class='gform-field-label gform-field-label--type-inline'>Soplo cardiaco<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.47' type='checkbox'  value='Problemas\/enfermedad de la tiroides'  id='choice_2_56_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_47' id='label_2_56_47' class='gform-field-label gform-field-label--type-inline'>Problemas\/enfermedad de la tiroides<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.48' type='checkbox'  value='Varicela'  id='choice_2_56_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_48' id='label_2_56_48' class='gform-field-label gform-field-label--type-inline'>Varicela<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.49' type='checkbox'  value='Hemofilia'  id='choice_2_56_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_49' id='label_2_56_49' class='gform-field-label gform-field-label--type-inline'>Hemofilia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.51' type='checkbox'  value='Amigdalitis'  id='choice_2_56_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_51' id='label_2_56_51' class='gform-field-label gform-field-label--type-inline'>Amigdalitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.52' type='checkbox'  value='Tos Cronica'  id='choice_2_56_52'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_52' id='label_2_56_52' class='gform-field-label gform-field-label--type-inline'>Tos Cronica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.53' type='checkbox'  value='Hepatitis'  id='choice_2_56_53'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_53' id='label_2_56_53' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.54' type='checkbox'  value='Tuberculosis'  id='choice_2_56_54'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_54' id='label_2_56_54' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.55' type='checkbox'  value='Herpes labial'  id='choice_2_56_55'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_55' id='label_2_56_55' class='gform-field-label gform-field-label--type-inline'>Herpes labial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.56' type='checkbox'  value='Herpes'  id='choice_2_56_56'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_56' id='label_2_56_56' class='gform-field-label gform-field-label--type-inline'>Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.57' type='checkbox'  value='\u00dalceras'  id='choice_2_56_57'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_57' id='label_2_56_57' class='gform-field-label gform-field-label--type-inline'>\u00dalceras<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_58'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.58' type='checkbox'  value='Lesiones cardiacas cong\u00e9nitas'  id='choice_2_56_58'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_58' id='label_2_56_58' class='gform-field-label gform-field-label--type-inline'>Lesiones cardiacas cong\u00e9nitas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_59'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.59' type='checkbox'  value='Presi\u00f3n arterial alta\/baja'  id='choice_2_56_59'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_59' id='label_2_56_59' class='gform-field-label gform-field-label--type-inline'>Presi\u00f3n arterial alta\/baja<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_61'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.61' type='checkbox'  value='Enfermedad ven\u00e9rea'  id='choice_2_56_61'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_61' id='label_2_56_61' class='gform-field-label gform-field-label--type-inline'>Enfermedad ven\u00e9rea<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_62'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.62' type='checkbox'  value='Lentes de contacto'  id='choice_2_56_62'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_62' id='label_2_56_62' class='gform-field-label gform-field-label--type-inline'>Lentes de contacto<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_63'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.63' type='checkbox'  value='Problema\/enfermedad renal'  id='choice_2_56_63'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_63' id='label_2_56_63' class='gform-field-label gform-field-label--type-inline'>Problema\/enfermedad renal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_64'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.64' type='checkbox'  value='Cortisona'  id='choice_2_56_64'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_64' id='label_2_56_64' class='gform-field-label gform-field-label--type-inline'>Cortisona<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_65'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.65' type='checkbox'  value='Enfermedad hepatica\/ictericia amarilla'  id='choice_2_56_65'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_65' id='label_2_56_65' class='gform-field-label gform-field-label--type-inline'>Enfermedad hepatica\/ictericia amarilla<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_2_56_66'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.66' type='checkbox'  value='Otra'  id='choice_2_56_66'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_2_56_66' id='label_2_56_66' class='gform-field-label gform-field-label--type-inline'>Otra<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_56_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Seleccionar todos\" data-label-deselect=\"Deseleccionar todos\">Seleccionar todos<\/button><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1 actualmente amamantando?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_57'>\n\t\t\t<div class='gchoice gchoice_2_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='S\u00ed'  id='choice_2_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_57_0' id='label_2_57_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_2_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='No'  id='choice_2_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_57_1' id='label_2_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfToma anticonceptivos con prescripci\u00f3n?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_58'>\n\t\t\t<div class='gchoice gchoice_2_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='S\u00ed'  id='choice_2_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_0' id='label_2_58_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_2_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='No'  id='choice_2_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_58_1' id='label_2_58_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfEst\u00e1 embarazada o piensa que pudiera estarlo<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_60'>\n\t\t\t<div class='gchoice gchoice_2_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='S\u00ed'  id='choice_2_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_60_0' id='label_2_60_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_2_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_2_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_60_1' id='label_2_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-horizontal\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>\u00bfTiene alg\u00fan problema relacionado con su per\u00edodo menstrual?<\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_2_59'>\n\t\t\t<div class='gchoice gchoice_2_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='S\u00ed'  id='choice_2_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_0' id='label_2_59_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_2_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='No'  id='choice_2_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_2_59_1' id='label_2_59_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_2_61\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>CONOCIMIENTO Y CONSENTIMIENTO<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_61'><div class='gfield_consent_description_text' tabindex='0'>Reconocimiento de la Autorizaci\u00f3n de Pago por el Seguro:<br \/>\n<br \/>\nPor este medio autorizo y ordeno que los beneficios de mi seguro dental se paguen directamente a Mannheim Dental. En caso de que mi seguro me env\u00ede el pago por error, entiendo que soy responsable de remitir dicho pago inmediatamente. Entiendo que Mannheim Dental, como cortes\u00eda, enviar\u00e1 la reclamaci\u00f3n a mi seguro. Si por cualquier motivo el seguro niega el pago, soy responsable del costo total de mi tratamiento.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_61.1' id='input_2_61_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_61\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_61_1' ><span class='gform-field-label__text'>Entiendo los t\u00e9rminos<\/span><\/label><input type='hidden' name='input_61.2' value='Entiendo los t\u00e9rminos' class='gform_hidden' \/><input type='hidden' name='input_61.3' value='11' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_62\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_62'><span class='gform-field-label__text'>FIRMA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_62_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_62_valid' id='input_2_62_valid' \/><canvas id='input_2_62' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mannheimdental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_62_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_62_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_62_data' name='input_2_62_data' value=''><\/div><\/div><div id=\"field_2_69\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p class=\"md-date-display\" style=\"margin:0;\">\n\t<strong>Date:<\/strong> <span class=\"md-today-text\"><\/span>\n<\/p>\n<script>\n(function () {\n\tvar HIDDEN_FIELD_ID = 68; \/\/ \u2190 CAMBIA por el ID del campo Hidden\n\n\tfunction setToday() {\n\t\tvar d = new Date(), p = function (n) { return (n < 10 ? '0' : '') + n; };\n\t\tvar hoy = p(d.getMonth() + 1) + '\/' + p(d.getDate()) + '\/' + d.getFullYear();\n\n\t\t\/\/ Muestra la fecha\n\t\tdocument.querySelectorAll('.md-today-text').forEach(function (s) { s.textContent = hoy; });\n\n\t\t\/\/ La guarda en el campo oculto\n\t\tdocument.querySelectorAll('input[name=\"input_' + HIDDEN_FIELD_ID + '\"]').forEach(function (i) { i.value = hoy; });\n\t}\n\n\tsetToday();\n\tdocument.addEventListener('DOMContentLoaded', setToday);\n\tif (window.jQuery) { jQuery(document).on('gform_post_render', setToday); }\n})();\n<\/script><\/div><div id=\"field_2_68\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='10\/19\/2026' \/><\/div><\/div><fieldset id=\"field_2_63\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Reconocimiento de responsabilidad Financiera<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_63'><div class='gfield_consent_description_text' tabindex='0'>Estoy de acuerdo en ser responsable por el pago de todos los servicios que se presten a mi nombre o a nombre de mis dependientes. Entiendo que el pago debe efectuarse en el momento de recibir el servicio, a menos que se hayan hecho otros acuerdos. En caso de que los pagos no se hagan en las fechas acordadas, entiendo que es posible que se sume a mi cuenta un cargo de $15 por pago tard\u00edo. Tambi\u00e9n estoy de acuerdo en informar a Mannheim Dental de cualquier cambio de domicilio, n\u00famero telef\u00f3nico o seguro dentro de los 30 d\u00edas siguientes a dicho cambio. En caso de no cumplir con estos requisitos, autorizo utilizar todos los medios debidos, inclusive el uso de registros de historial de cr\u00e9dito, para averiguar mi nueva direcci\u00f3n con prop\u00f3sitos de cobro.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_63.1' id='input_2_63_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_63\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_63_1' ><span class='gform-field-label__text'>Entiendo los t\u00e9rminos<\/span><\/label><input type='hidden' name='input_63.2' value='Entiendo los t\u00e9rminos' class='gform_hidden' \/><input type='hidden' name='input_63.3' value='11' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_64\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_64'><span class='gform-field-label__text'>FIRMA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_64_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_64_valid' id='input_2_64_valid' \/><canvas id='input_2_64' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mannheimdental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_64_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_64_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_64_data' name='input_2_64_data' value=''><\/div><\/div><div id=\"field_2_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p class=\"md-date-display\" style=\"margin:0;\">\n\t<strong>Date:<\/strong> <span class=\"md-today-text\"><\/span>\n<\/p>\n<script>\n(function () {\n\tvar HIDDEN_FIELD_ID = 68; \/\/ \u2190 CAMBIA por el ID del campo Hidden\n\n\tfunction setToday() {\n\t\tvar d = new Date(), p = function (n) { return (n < 10 ? '0' : '') + n; };\n\t\tvar hoy = p(d.getMonth() + 1) + '\/' + p(d.getDate()) + '\/' + d.getFullYear();\n\n\t\t\/\/ Muestra la fecha\n\t\tdocument.querySelectorAll('.md-today-text').forEach(function (s) { s.textContent = hoy; });\n\n\t\t\/\/ La guarda en el campo oculto\n\t\tdocument.querySelectorAll('input[name=\"input_' + HIDDEN_FIELD_ID + '\"]').forEach(function (i) { i.value = hoy; });\n\t}\n\n\tsetToday();\n\tdocument.addEventListener('DOMContentLoaded', setToday);\n\tif (window.jQuery) { jQuery(document).on('gform_post_render', setToday); }\n})();\n<\/script><\/div><div id=\"field_2_70\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_70' id='input_2_70' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='10\/19\/2026' \/><\/div><\/div><fieldset id=\"field_2_71\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Aviso de Privacidad<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_71'><div class='gfield_consent_description_text' tabindex='0'>Reconozco que he recibido informaci\u00f3n sobre las pr\u00e1cticas de privacidad, que describe las formas en que la cl\u00ednica puede utilizar y divulgar mi informaci\u00f3n de salud para mi tratamiento, pago, operaciones de atenci\u00f3n m\u00e9dica y otros usos y divulgaciones permitidos que all\u00ed se describen. Entiendo que puedo comunicarme con el oficial de privacidad designado en el aviso si tengo alguna pregunta o queja. En la medida permitida por la ley, doy mi consentimiento para el uso y la divulgaci\u00f3n de mi informaci\u00f3n para los fines descritos en el Aviso de Pr\u00e1cticas de Privacidad de la cl\u00ednica.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_71.1' id='input_2_71_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_71\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_71_1' ><span class='gform-field-label__text'>Entiendo los t\u00e9rminos y condiciones<\/span><\/label><input type='hidden' name='input_71.2' value='Entiendo los t\u00e9rminos y condiciones' class='gform_hidden' \/><input type='hidden' name='input_71.3' value='11' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_74\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_74'><span class='gform-field-label__text'>FIRMA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_74_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_74_valid' id='input_2_74_valid' \/><canvas id='input_2_74' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mannheimdental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_74_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_74_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_74_data' name='input_2_74_data' value=''><\/div><\/div><div id=\"field_2_72\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p class=\"md-date-display\" style=\"margin:0;\">\n\t<strong>Date:<\/strong> <span class=\"md-today-text\"><\/span>\n<\/p>\n<script>\n(function () {\n\tvar HIDDEN_FIELD_ID = 68; \/\/ \u2190 CAMBIA por el ID del campo Hidden\n\n\tfunction setToday() {\n\t\tvar d = new Date(), p = function (n) { return (n < 10 ? '0' : '') + n; };\n\t\tvar hoy = p(d.getMonth() + 1) + '\/' + p(d.getDate()) + '\/' + d.getFullYear();\n\n\t\t\/\/ Muestra la fecha\n\t\tdocument.querySelectorAll('.md-today-text').forEach(function (s) { s.textContent = hoy; });\n\n\t\t\/\/ La guarda en el campo oculto\n\t\tdocument.querySelectorAll('input[name=\"input_' + HIDDEN_FIELD_ID + '\"]').forEach(function (i) { i.value = hoy; });\n\t}\n\n\tsetToday();\n\tdocument.addEventListener('DOMContentLoaded', setToday);\n\tif (window.jQuery) { jQuery(document).on('gform_post_render', setToday); }\n})();\n<\/script><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_73' id='input_2_73' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='10\/19\/2026' \/><\/div><\/div><fieldset id=\"field_2_75\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Aviso de Citas perdidas o Canceladas<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_2_75'><div class='gfield_consent_description_text' tabindex='0'>Si usted no puede asistir a su cita programada, Mannheim Dental requiere un aviso con 24 horas de anticipaci\u00f3n; de lo contrario, se agregar\u00e1 un cargo de $50 a su cuenta, el cual deber\u00e1 pagarse de inmediato. Despu\u00e9s de tres citas canceladas o perdidas sin aviso, Mannheim Dental se reserva el derecho de terminar la relaci\u00f3n paciente\/doctor.<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_75.1' id='input_2_75_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_2_75\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_75_1' ><span class='gform-field-label__text'>Entiendo los t\u00e9rminos y condiciones<\/span><\/label><input type='hidden' name='input_75.2' value='Entiendo los t\u00e9rminos y condiciones' class='gform_hidden' \/><input type='hidden' name='input_75.3' value='11' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_78\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_78'><span class='gform-field-label__text'>FIRMA<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_78_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_78_valid' id='input_2_78_valid' \/><canvas id='input_2_78' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mannheimdental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_78_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_78_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_78_data' name='input_2_78_data' value=''><\/div><\/div><div id=\"field_2_76\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p class=\"md-date-display\" style=\"margin:0;\">\n\t<strong>Date:<\/strong> <span class=\"md-today-text\"><\/span>\n<\/p>\n<script>\n(function () {\n\tvar HIDDEN_FIELD_ID = 68; \/\/ \u2190 CAMBIA por el ID del campo Hidden\n\n\tfunction setToday() {\n\t\tvar d = new Date(), p = function (n) { return (n < 10 ? '0' : '') + n; };\n\t\tvar hoy = p(d.getMonth() + 1) + '\/' + p(d.getDate()) + '\/' + d.getFullYear();\n\n\t\t\/\/ Muestra la fecha\n\t\tdocument.querySelectorAll('.md-today-text').forEach(function (s) { s.textContent = hoy; });\n\n\t\t\/\/ La guarda en el campo oculto\n\t\tdocument.querySelectorAll('input[name=\"input_' + HIDDEN_FIELD_ID + '\"]').forEach(function (i) { i.value = hoy; });\n\t}\n\n\tsetToday();\n\tdocument.addEventListener('DOMContentLoaded', setToday);\n\tif (window.jQuery) { jQuery(document).on('gform_post_render', setToday); }\n})();\n<\/script><\/div><div id=\"field_2_77\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_77' id='input_2_77' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='10\/19\/2026' \/><\/div><\/div><fieldset id=\"field_2_79\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>CONSENTIMIENTO<\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_79.1' id='input_2_79_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_2_79_1' ><span class='gform-field-label__text'>Reconozco que he recibido y leido la hoja de datos de materiales dentales antes de iniciar el trabajo en Mannheim Dental<\/span><\/label><input type='hidden' name='input_79.2' value='Reconozco que he recibido y leido la hoja de datos de materiales dentales antes de iniciar el trabajo en Mannheim Dental' class='gform_hidden' \/><input type='hidden' name='input_79.3' value='11' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_2_80\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_80'><span class='gform-field-label__text'>FIRMA<\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_2_80_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_2_80_valid' id='input_2_80_valid' \/><canvas id='input_2_80' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/mannheimdental.com\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_2_80_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_2_80_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_2_80_data' name='input_2_80_data' value=''><\/div><\/div><div id=\"field_2_81\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full exclude gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><p class=\"md-date-display\" style=\"margin:0;\">\n\t<strong>Date:<\/strong> <span class=\"md-today-text\"><\/span>\n<\/p>\n<script>\n(function () {\n\tvar HIDDEN_FIELD_ID = 68; \/\/ \u2190 CAMBIA por el ID del campo Hidden\n\n\tfunction setToday() {\n\t\tvar d = new Date(), p = function (n) { return (n < 10 ? '0' : '') + n; };\n\t\tvar hoy = p(d.getMonth() + 1) + '\/' + p(d.getDate()) + '\/' + d.getFullYear();\n\n\t\t\/\/ Muestra la fecha\n\t\tdocument.querySelectorAll('.md-today-text').forEach(function (s) { s.textContent = hoy; });\n\n\t\t\/\/ La guarda en el campo oculto\n\t\tdocument.querySelectorAll('input[name=\"input_' + HIDDEN_FIELD_ID + '\"]').forEach(function (i) { i.value = hoy; });\n\t}\n\n\tsetToday();\n\tdocument.addEventListener('DOMContentLoaded', setToday);\n\tif (window.jQuery) { jQuery(document).on('gform_post_render', setToday); }\n})();\n<\/script><\/div><div id=\"field_2_82\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_above field_validation_above gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_82' id='input_2_82' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='10\/19\/2026' 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Por favor, desactiva el marcado obsoleto en los ajustes del formulario para activar el cambio de tama\\u00f1o en vivo.\",\"thisConfirmation\":\"Usar esta confirmaci\\u00f3n si\",\"thisNotification\":\"Enviar esta notificaci\\u00f3n si\",\"confirmationSave\":\"Guardar\",\"confirmationSaving\":\"Guardando...\",\"confirmationAreYouSure\":\"\\u00bfEst\\u00e1s seguro de que deseas cancelar estos cambios?\",\"confirmationIssueSaving\":\"Hubo un problema al guardar esta confirmaci\\u00f3n.\",\"confirmationConfirmDelete\":\"\\u00bfSeguro que quieres borrar esta confirmaci\\u00f3n?\",\"confirmationIssueDeleting\":\"Hubo un problema al borrar esta confirmaci\\u00f3n.\",\"confirmationConfirmDiscard\":\"Hay cambios sin guardar en la confirmaci\\u00f3n actual. \\u00bfTe gustar\\u00eda descartar estos cambios?\",\"confirmationDefaultName\":\"Confirmaci\\u00f3n sin t\\u00edtulo\",\"confirmationDefaultMessage\":\"\\u00a1Gracias por contactar con nosotros! Nos pondremos en contacto contigo muy pronto.\",\"confirmationInvalidPageSelection\":\"Selecciona una p\\u00e1gina.\",\"confirmationInvalidRedirect\":\"Introduce una URL.\",\"confirmationInvalidName\":\"Introduce un nombre de confirmaci\\u00f3n.\",\"confirmationDeleteField\":\"Al borrar este campo tambi\\u00e9n se borrar\\u00e1n todos los datos de entrada asociados a \\u00e9l. \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"confirmationDeleteDisplayField\":\"Est\\u00e1s a punto de borrar este campo. \\u00abCancelar\\u00bb para parar. \\u00abAceptar\\u00bb para borrar\",\"confirmationDeleteDisplayFieldTitle\":\"Advertencia\",\"conditionalLogicDependency\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de este campo. Borrar este campo desactivar\\u00e1 esas reglas de l\\u00f3gica condicional y tambi\\u00e9n todos los datos asociados con el campo en las entradas. 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyChoice\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de esta opci\\u00f3n \\u00bfest\\u00e1s seguro de que quieres borrarla?. 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyChoiceEdit\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de esta opci\\u00f3n. \\u00bfEst\\u00e1s seguro de editar esta opci\\u00f3n? 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyAdminOnly\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de este campo. \\u00bfEst\\u00e1s seguro de que quieres marcar este campo como Administrativo? 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicRichTextEditorWarning\":\"Este formulario contiene l\\u00f3gica condicional que depende de este campo. No seguir\\u00e1 funcionando si est\\u00e1 activado el editor de texto enriquecido.  \\u00bfQuieres activar el editor de texto enriquecido? \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para continuar.\",\"conditionalLogicTypeButton\":\"bot\\u00f3n\",\"conditionalLogicTypeConfirmation\":\"confirmaci\\u00f3n\",\"conditionalLogicTypeNotification\":\"aviso\",\"conditionalLogicTypeNoficationRouting\":\"enrutamiento de avisos\",\"conditionalLogicTypeField\":\"campo\",\"conditionalLogicTypeFeed\":\"feed\",\"conditionalLogicWarningTitle\":\"Advertencia de l\\u00f3gica condicional\",\"mergeTagsText\":\"Insertar etiquetas de fusi\\u00f3n\",\"baseUrl\":\"https:\\\/\\\/mannheimdental.com\\\/wp-content\\\/plugins\\\/gravityforms\",\"gf_currency_config\":{\"name\":\"D\\u00f3lar Americano\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"otherChoiceValue\":\"Otro\",\"isFormTrash\":false,\"currentlyAddingField\":false,\"visibilityOptions\":[{\"label\":\"Visible\",\"value\":\"visible\",\"description\":\"Opci\\u00f3n predeterminada. El campo ser\\u00e1 visible cuando se vea el formulario.\"},{\"label\":\"Oculto\",\"value\":\"hidden\",\"description\":\"El campo est\\u00e1 oculto cuando se ve el formulario. \\u00datil cuando necesitas la funcionalidad de este campo pero no quieres que el usurario pueda verlo.\"},{\"label\":\"Administrativo\",\"value\":\"administrative\",\"description\":\"Este campo s\\u00f3lo es visible al administrar entradas enviadas. El campo no es visible o funcional cuando se ve el formulario.\"}],\"addFieldFilter\":\"A\\u00f1adir una condici\\u00f3n\",\"removeFieldFilter\":\"Eliminar una condici\\u00f3n\",\"filterAndAny\":\"{0} de los siguientes coinciden:\",\"customChoices\":\"Opciones personalizadas\",\"predefinedChoices\":\"Opciones predefinidas\",\"fieldLabelAriaLabel\":\"{field_label} - {field_type}, saltar a los ajustes de este campo\",\"fieldCanBeAddedTitle\":\"L\\u00edmite de campo\",\"fieldCanBeAddedMessage\":\"A form can only contain one {field_type} field.\",\"fieldCanBeAddedProductTitle\":\"Falta el campo de producto\",\"fieldCanBeAddedProduct\":\"Debes a\\u00f1adir un campo de producto primero.\",\"fieldForbiddenInRepeaterTitle\":\"Unrepeatable Field\",\"fieldForbiddenInRepeater\":\"{field_type} fields are not supported in Repeaters.\",\"legacyMarkupTitle\":\"Marcado no compatible\",\"fieldCanBeAddedMultipleChoice\":\"No puedes a\\u00f1adir un campo de opci\\u00f3n m\\u00faltiple a un formulario que utiliza marcado heredado. Edita la configuraci\\u00f3n del formulario y desactiva el marcado heredado.\",\"fieldCanBeAddedImageChoice\":\"No puedes a\\u00f1adir un campo de elecci\\u00f3n de imagen a un formulario que utiliza marcado heredado. Edita la configuraci\\u00f3n del formulario y desactiva el marcado heredado.\",\"FieldAjaxonErrorTitle\":\"Error\",\"StartAddFieldAjaxonError\":\"Error de Ajax al a\\u00f1adir un campo. Por favor, actualiza la p\\u00e1gina e int\\u00e9ntalo de nuevo.\",\"StartChangeInputTypeAjaxonError\":\"Error deAjax al cambiar el tipo de entrada. Por favor, actualiza la p\\u00e1gina e int\\u00e9ntalo de nuevo.\",\"MissingNameCustomChoicesTitle\":\"Falta el nombre\",\"MissingNameCustomChoices\":\"Por favor, dale un nombre a esta elecci\\u00f3n personalizada.\",\"DuplicateNameCustomChoicesTitle\":\"Duplicar t\\u00edtulo\",\"DuplicateNameCustomChoices\":\"Esta elecci\\u00f3n personalizada ya est\\u00e1 en uso. Por favor selecciona otro nombre.\",\"DuplicateTitleMessageTitle\":\"Duplicar t\\u00edtulo\",\"DuplicateTitleMessage\":\"El t\\u00edtulo de formulario que has introducido ya est\\u00e1 en uso. Por favor introduce un t\\u00edtulo de formulario \\u00fanico.\",\"ValidateFormMissingFormTitleTitle\":\"Falta el t\\u00edtulo del formulario\",\"ValidateFormMissingFormTitle\":\"Introduce un t\\u00edtulo para este formulario. Cuando a\\u00f1adas un formulario a una entrada o p\\u00e1gina, tendr\\u00e1s la opci\\u00f3n de ocultar el t\\u00edtulo.\",\"ValidateFormEmptyPageTitle\":\"Pagina vacia\",\"ValidateFormEmptyPage\":\"Este formulario tiene actualmente una o m\\u00e1s p\\u00e1ginas sin ning\\u00fan campo. Las p\\u00e1ginas en blanco son el resultado de los saltos de p\\u00e1gina que est\\u00e1n colocados como primer o \\u00faltimo campo del formulario o justo uno detr\\u00e1s de otro. Ajusta los saltos de p\\u00e1gina.\",\"ValidateFormMissingProductLabelTitle\":\"Falta la etiqueta del producto\",\"ValidateFormMissingProductLabel\":\"Este formulario tiene un campo de producto con una etiqueta en blanco. Por favor, introduce una etiqueta para cada campo de producto.\",\"ValidateFormMissingProductFieldTitle\":\"Falta el campo de producto\",\"ValidateFormMissingProductField\":\"Este formulario tiene un campo de opci\\u00f3n sin un campo de producto. Debes a\\u00f1adir un campo de producto a tu formulario.\",\"FormulaIsValidTitle\":\"Correcto\",\"FormulaIsValid\":\"La f\\u00f3rmula parece ser v\\u00e1lida.\",\"FormulaIsInvalid\":\"Parece que hay un problema con la f\\u00f3rmula.\",\"DeleteFormTitle\":\"Confirmar\",\"DeleteForm\":\"Est\\u00e1s a punto de mover este formulario a la papelera. \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"DeleteCustomChoice\":\"\\u00bfBorrar esta lista de opciones personalizada? \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"FieldAdded\":\"&nbsp;campo a\\u00f1adido al formulario\",\"nameFieldDefaultPrefixes\":[{\"text\":\"Dr.\",\"value\":\"Dr.\"},{\"text\":\"Prof.\",\"value\":\"Prof.\"},{\"text\":\"Rev.\",\"value\":\"Rev.\"},{\"text\":\"Sr.\",\"value\":\"Sr.\"},{\"text\":\"Sra.\",\"value\":\"Sra.\"},{\"text\":\"Srta.\",\"value\":\"Srta.\"}]};\t\t\t<\/script>\n\n            \t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9665712 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" data-id=\"9665712\" data-element_type=\"widget\" data-e-type=\"widget\" data-no-translation=\"\" data-widget_type=\"eael-gravity-form.default\">\n\t\t\t\t\t<style>.elementor-element-9665712{display:none !important}<\/style>\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-1f15404 e-con e-atomic-element e-flexbox-base e-default-div e-1f15404-fc45052 \" data-id=\"1f15404\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"1f15404\" data-e-type=\"e-flexbox\" data-id=\"1f15404\">\n    \n<\/div>\n\n<\/div>\n<div class=\"elementor-element elementor-element-63ed5c0 e-con e-atomic-element e-flexbox-base e-default-div e-63ed5c0-b7b54e6 \" data-id=\"63ed5c0\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"63ed5c0\" data-e-type=\"e-flexbox\" data-id=\"63ed5c0\">\n    <div class=\"elementor-element elementor-element-7583bd6 e-con e-atomic-element e-flexbox-base e-default-div e-7583bd6-a2a6f91 \" data-id=\"7583bd6\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"7583bd6\" data-e-type=\"e-flexbox\" data-id=\"7583bd6\">\n    \n<\/div>\n<div class=\"elementor-element elementor-element-13cb721 e-con e-atomic-element e-flexbox-base e-default-div e-13cb721-e78c8df \" data-id=\"13cb721\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"13cb721\" data-e-type=\"e-flexbox\" data-id=\"13cb721\">\n    \t\t<div class=\"elementor-element elementor-element-60ca191 elementor-widget elementor-widget-jet-form-builder-form\" data-id=\"60ca191\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jet-form-builder-form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='wp-block-library-css' href='https:\/\/mannheimdental.com\/wp-includes\/css\/dist\/block-library\/common.min.css?ver=7.1.3' media='all' \/>\n<style id=\"jet-form-builder-1133-inline-css\"><\/style><form  class=\"jet-form-builder layout-column submit-type-reload\" action=\"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages\/120\/?59t9cv=2x35VZj69Fi1&amp;method=reload\" method=\"POST\" data-form-id=\"1133\" data-layout=\"column\" enctype=\"multipart\/form-data\" novalidate=\"null\" ssr_validation_method=\"rest\"><input type=\"hidden\" id=\"_wpnonce_1133\" name=\"_wpnonce\" value=\"0ceeadf7c1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/120\" \/>\r\n<input type=\"hidden\" name=\"_jfb_current_render_states[]\" value=\"DEFAULT.STATE\" data-jfb-sync \/><input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_booking_form_id\" data-field-name=\"_jet_engine_booking_form_id\" value=\"1133\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"_jet_engine_refer\" data-field-name=\"_jet_engine_refer\" value=\"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages\/120\/\">\n<input type=\"hidden\" class=\"jet-form-builder__field hidden-field\" name=\"__queried_post_id\" data-field-name=\"__queried_post_id\" value=\"120\">\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field cb-pe9jdg16\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">FULL NAME <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input required=\"required\" name=\"full_name\" id=\"full_name\" type=\"text\" data-field-name=\"full_name\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_u8UpEsQe\">\n\t\t\t\t\t<\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-phone-field cb-nzpvqwjh\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">PHONE NUMBER<\/div><\/div><div class=\"jet-form-builder__field-wrap phone-field-wrap \">\n\t\n\t<input type=\"tel\" name=\"phone_number\" id=\"phone_number\" data-field-name=\"phone_number\" class=\"jet-form-builder__field phone-field\" data-jfb-sync=\"null\" autocomplete=\"tel\" data-default-country=\"auto\" data-save-format=\"e164\" data-validation-message-required=\"Required field is empty\" data-validation-message-invalid=\"Please enter a valid phone number\">\n\n\t<input\n\t\ttype=\"tel\"\n\t\tname=\"phone_number_intl\"\n\t\tdata-field-name=\"phone_number_intl\"\n\t\tclass=\"jet-form-builder__field phone-field-intl  \"\n\t\tvalue=\"\"\n\t\tautocomplete=\"tel\"\n\t>\n\n\t<\/div>\n<\/div><\/div>\n<\/div>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field cb-jyi21929\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">EMAIL<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"email\" id=\"email\" type=\"email\" data-field-name=\"email\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_5IQp0E98\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-date-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">PREFERRED DATE<\/div><\/div><input class=\"jet-form-builder__field date-field\" name=\"preferres_date\" type=\"date\" data-field-name=\"preferres_date\" id=\"preferres_date\" data-jfb-sync=\"null\">\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-date-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">DATE OF BIRTH<\/div><\/div><input class=\"jet-form-builder__field date-field\" name=\"date_of_birth\" type=\"date\" data-field-name=\"date_of_birth\" id=\"date_of_birth\" data-jfb-sync=\"null\">\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-time-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">PREFERRED TIME<\/div><\/div><input class=\"jet-form-builder__field time-field\" name=\"preferred_time\" id=\"preferred_time\" type=\"time\" data-field-name=\"preferred_time\" data-jfb-sync=\"null\">\n<\/div><\/div>\n<\/div>\n\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-x5xyqzon\">\n<div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"field_name\" value=\"new\" data-field-name=\"field_name\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NEW PATIENT<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"field_name\" value=\"existing\" data-field-name=\"field_name\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>EXISTING PATIENT<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div class=\"jet-form-builder__conditional \" data-jfb-conditional=\"[]\" data-jfb-func=\"\">\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field cb-zygnvzqb\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">FIRST NAME<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"first_name\" id=\"first_name\" type=\"text\" data-field-name=\"first_name\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_0etGgJvE\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-ivj32nx4\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">MIDDLE NAME<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"middle_name\" id=\"middle_name\" type=\"text\" data-field-name=\"middle_name\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_Hh3TZaIQ\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-em44lnas\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">ADDRESS<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"address\" id=\"address\" type=\"text\" data-field-name=\"address\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_eEasgyNB\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-beufrh09\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">CITY<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"city\" id=\"city\" type=\"text\" data-field-name=\"city\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_AhWizvKs\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-nilixznb\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">STATE<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"state\" id=\"state\" type=\"text\" data-field-name=\"state\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_zq2iwXGA\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-ng8y3wfh\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">ZIP CODE<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"zip_code\" id=\"zip_code\" type=\"text\" data-field-name=\"zip_code\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_wBsVtEhH\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field cb-c9j2h2fh\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">GENDER<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" name=\"gender\" data-field-name=\"gender\" id=\"gender\" data-jfb-sync=\"null\">\n\t\t<option value=\"0\" >MALE<\/option><option value=\"1\" >FEMALE<\/option><option value=\"2\" >NOT SPECIFIED<\/option><option value=\"3\" >OTHER<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field cb-c0r3gch3\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">What pronouns do you use?<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" name=\"what_pronouns_do_you_use\" data-field-name=\"what_pronouns_do_you_use\" id=\"what_pronouns_do_you_use\" data-jfb-sync=\"null\">\n\t\t<option value=\"0\" >He \/ Him<\/option><option value=\"1\" >She \/ Her<\/option><option value=\"2\" >They \/ Them<\/option><option value=\"3\" >Prefer not to answer<\/option><option value=\"4\" >Other<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field cb-yzajayk9\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">MARITAL STATUS<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" name=\"marital_status\" data-field-name=\"marital_status\" id=\"marital_status\" data-jfb-sync=\"null\">\n\t\t<option value=\"0\" >Married<\/option><option value=\"1\" >Single<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-phone-field cb-ar6gzog2\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">CELL PHONE<\/div><\/div><div class=\"jet-form-builder__field-wrap phone-field-wrap \">\n\t\n\t<input type=\"tel\" name=\"cell_phone\" id=\"cell_phone\" data-field-name=\"cell_phone\" class=\"jet-form-builder__field phone-field\" data-jfb-sync=\"null\" autocomplete=\"tel\" data-default-country=\"auto\" data-save-format=\"e164\" data-validation-message-required=\"Required field is empty\" data-validation-message-invalid=\"Please enter a valid phone number\">\n\n\t<input\n\t\ttype=\"tel\"\n\t\tname=\"cell_phone_intl\"\n\t\tdata-field-name=\"cell_phone_intl\"\n\t\tclass=\"jet-form-builder__field phone-field-intl  \"\n\t\tvalue=\"\"\n\t\tautocomplete=\"tel\"\n\t>\n\n\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-number-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">SOCIAL SECURITY NUMBER<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t<input type=\"number\" class=\"jet-form-builder__field text-field\" name=\"social_security_number\" data-field-name=\"social_security_number\" id=\"social_security_number\" data-jfb-sync=\"null\">\n\t<\/div>\n<\/div>\n\n\n<div style=\"height:60px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>IF THE PATIENT IS A MINOR, PLEASE PROVIDE THE FOLLOWING<\/strong><\/p>\n\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-text-field cb-dhvt4fr0\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">PARENT OR GUARDIAN NAME<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"parent_or_guardian_name\" id=\"parent_or_guardian_name\" type=\"text\" data-field-name=\"parent_or_guardian_name\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_lqCTD2sM\">\n\t\t\t\t\t<\/div>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field cb-fj4m0bf8\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">RELATIONSHIP<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" name=\"relationship\" data-field-name=\"relationship\" id=\"relationship\" data-jfb-sync=\"null\">\n\t\t<option value=\"0\" >PARENT<\/option><option value=\"1\" > GRANDPARENT<\/option><option value=\"2\" > OTHER<\/option><option value=\"3\" > LEGAL GUARDIAN<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-mq030eo7\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">EMAIL<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"email_copy\" id=\"email_copy\" type=\"email\" data-field-name=\"email_copy\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_fh6YHaEi\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-ditdlxvu\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">DOMICILIO<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"domicilio\" id=\"domicilio\" type=\"text\" data-field-name=\"domicilio\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_frOYqPsT\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-lnalntpv\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">CITY<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"city_copy\" id=\"city_copy\" type=\"text\" data-field-name=\"city_copy\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_AjxIn3o0\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-e65pk62s\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">STATE<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"state_copy\" id=\"state_copy\" type=\"text\" data-field-name=\"state_copy\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_4zZVjshG\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-phone-field cb-giv4sbdl\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">CELL PHONE<\/div><\/div><div class=\"jet-form-builder__field-wrap phone-field-wrap \">\n\t\n\t<input type=\"tel\" name=\"cell_phone_copy\" id=\"cell_phone_copy\" data-field-name=\"cell_phone_copy\" class=\"jet-form-builder__field phone-field\" data-jfb-sync=\"null\" autocomplete=\"tel\" data-default-country=\"auto\" data-save-format=\"e164\" data-validation-message-required=\"Required field is empty\" data-validation-message-invalid=\"Please enter a valid phone number\">\n\n\t<input\n\t\ttype=\"tel\"\n\t\tname=\"cell_phone_copy_intl\"\n\t\tdata-field-name=\"cell_phone_copy_intl\"\n\t\tclass=\"jet-form-builder__field phone-field-intl  \"\n\t\tvalue=\"\"\n\t\tautocomplete=\"tel\"\n\t>\n\n\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-phone-field cb-j9muekhn\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">HOUSE PHONE<\/div><\/div><div class=\"jet-form-builder__field-wrap phone-field-wrap \">\n\t\n\t<input type=\"tel\" name=\"cell_phone_copy_copy\" id=\"cell_phone_copy_copy\" data-field-name=\"cell_phone_copy_copy\" class=\"jet-form-builder__field phone-field\" data-jfb-sync=\"null\" autocomplete=\"tel\" data-default-country=\"auto\" data-save-format=\"e164\" data-validation-message-required=\"Required field is empty\" data-validation-message-invalid=\"Please enter a valid phone number\">\n\n\t<input\n\t\ttype=\"tel\"\n\t\tname=\"cell_phone_copy_copy_intl\"\n\t\tdata-field-name=\"cell_phone_copy_copy_intl\"\n\t\tclass=\"jet-form-builder__field phone-field-intl  \"\n\t\tvalue=\"\"\n\t\tautocomplete=\"tel\"\n\t>\n\n\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-number-field\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">SOCIAL SECURITY NUMBER<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t<input type=\"number\" class=\"jet-form-builder__field text-field\" name=\"social_security_number_copy\" data-field-name=\"social_security_number_copy\" id=\"social_security_number_copy\" data-jfb-sync=\"null\">\n\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-select-field wp-block-jet-forms-select-field cb-b3l1jojo\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">WHO DOES THE MINOR LIVE WITH?<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t<select class=\"jet-form-builder__field select-field\" name=\"who_does_the_minor_live_with\" data-field-name=\"who_does_the_minor_live_with\" id=\"who_does_the_minor_live_with\" data-jfb-sync=\"null\">\n\t\t<option value=\"0\" >MOTHER<\/option><option value=\"1\" >FATHER<\/option><option value=\"2\" > BOTH PARENTS<\/option><option value=\"3\" >OTHER<\/option>\t<\/select>\n<\/div>\n<\/div>\n\n\n<div style=\"height:60px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>EMERGENCY INFORMATION<\/strong><\/p>\n\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-up3c99jo\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">EMERGENCY CONTACT<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"emergency_contact\" id=\"emergency_contact\" type=\"text\" data-field-name=\"emergency_contact\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_MHC46J8e\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-phone-field cb-n7pdthho\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">PHONE NUMBER<\/div><\/div><div class=\"jet-form-builder__field-wrap phone-field-wrap \">\n\t\n\t<input type=\"tel\" name=\"phone_number\" id=\"phone_number_1\" data-field-name=\"phone_number\" class=\"jet-form-builder__field phone-field\" data-jfb-sync=\"null\" autocomplete=\"tel\" data-default-country=\"auto\" data-save-format=\"e164\" data-validation-message-required=\"Required field is empty\" data-validation-message-invalid=\"Please enter a valid phone number\">\n\n\t<input\n\t\ttype=\"tel\"\n\t\tname=\"phone_number_intl\"\n\t\tdata-field-name=\"phone_number_intl\"\n\t\tclass=\"jet-form-builder__field phone-field-intl  \"\n\t\tvalue=\"\"\n\t\tautocomplete=\"tel\"\n\t>\n\n\t<\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-text-field cb-js2oc9ig\" >\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">RELATIONSHIP<\/div><\/div><div class=\"jet-form-builder__field-wrap\">\n\t\t\t\t<input name=\"relationship\" id=\"relationship_1\" type=\"text\" data-field-name=\"relationship\" class=\"jet-form-builder__field text-field\" data-jfb-sync=\"null\" autocomplete=\"off_VCwsf1Rc\">\n\t\t\t\t\t<\/div>\n<\/div>\n\n\n<div style=\"height:60px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>MEDICAL HISTORY<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">The following questions are for your benefit and help ensure that any dental treatment takes your past and present health into account. Some questions may seem unrelated to your dental condition, but they are all connected to your oral health care. Please answer every question.<\/p>\n\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-ip02qhyq\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you taken any medication or drugs during the past two years?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_taken_any_medication_or_drugs_during_the_past_two_years\" value=\"0\" data-field-name=\"have_you_taken_any_medication_or_drugs_during_the_past_two_years\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_taken_any_medication_or_drugs_during_the_past_two_years\" value=\"1\" data-field-name=\"have_you_taken_any_medication_or_drugs_during_the_past_two_years\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-lql7e6je\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Are you currently taking any medications, drugs, pills, or herbal remedies, including aspirin?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_currently_taking_any_medications_drugs_pills_or_herbal__\" value=\"0\" data-field-name=\"are_you_currently_taking_any_medications_drugs_pills_or_herbal__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_currently_taking_any_medications_drugs_pills_or_herbal__\" value=\"1\" data-field-name=\"are_you_currently_taking_any_medications_drugs_pills_or_herbal__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-qdrzxul9\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Are you sensitive or allergic to any substance or medication?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_sensitive_or_allergic_to_any_substance_or_medication\" value=\"0\" data-field-name=\"are_you_sensitive_or_allergic_to_any_substance_or_medication\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_sensitive_or_allergic_to_any_substance_or_medication\" value=\"1\" data-field-name=\"are_you_sensitive_or_allergic_to_any_substance_or_medication\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-kwxy2gq8\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you ever taken prescription weight-loss medication (diet pills)?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_taken_prescription_weight_loss_medication_diet_pills\" value=\"0\" data-field-name=\"have_you_ever_taken_prescription_weight_loss_medication_diet_pills\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_taken_prescription_weight_loss_medication_diet_pills\" value=\"1\" data-field-name=\"have_you_ever_taken_prescription_weight_loss_medication_diet_pills\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-w18e0tfm\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you ever taken medication to treat or prevent osteoporosis, such as Fosamax, Actonel, Boniva, or a similar drug?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_taken_medication_to_treat_or_prevent_osteoporosis__\" value=\"0\" data-field-name=\"have_you_ever_taken_medication_to_treat_or_prevent_osteoporosis__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_taken_medication_to_treat_or_prevent_osteoporosis__\" value=\"1\" data-field-name=\"have_you_ever_taken_medication_to_treat_or_prevent_osteoporosis__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-bq4ieeto\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you been hospitalized in the past five years?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_been_hospitalized_in_the_past_five_years\" value=\"0\" data-field-name=\"have_you_been_hospitalized_in_the_past_five_years\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_been_hospitalized_in_the_past_five_years\" value=\"1\" data-field-name=\"have_you_been_hospitalized_in_the_past_five_years\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-kks6mkty\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you ever had a serious head or mouth injury?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_had_a_serious_head_or_mouth_injury\" value=\"0\" data-field-name=\"have_you_ever_had_a_serious_head_or_mouth_injury\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_had_a_serious_head_or_mouth_injury\" value=\"1\" data-field-name=\"have_you_ever_had_a_serious_head_or_mouth_injury\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-hl3qc73b\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you ever been told to take premedication before dental treatment?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_been_told_to_take_premedication_before_dental_treatment\" value=\"0\" data-field-name=\"have_you_ever_been_told_to_take_premedication_before_dental_treatment\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_ever_been_told_to_take_premedication_before_dental_treatment\" value=\"1\" data-field-name=\"have_you_ever_been_told_to_take_premedication_before_dental_treatment\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-tgs02z2l\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Is there anything else about having dental treatment that you would like us to know?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"is_there_anything_else_about_having_dental_treatment_that_you__\" value=\"0\" data-field-name=\"is_there_anything_else_about_having_dental_treatment_that_you__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"is_there_anything_else_about_having_dental_treatment_that_you__\" value=\"1\" data-field-name=\"is_there_anything_else_about_having_dental_treatment_that_you__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-n7a5wc64\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Do you have, or have you had, any disease, condition, or problem not listed above?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\" value=\"0\" data-field-name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\" value=\"1\" data-field-name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-s5liwiuw\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Have you lost or gained more than 10 pounds in the past year?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_lost_or_gained_more_than_10_pounds_in_the_past_year\" value=\"0\" data-field-name=\"have_you_lost_or_gained_more_than_10_pounds_in_the_past_year\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"have_you_lost_or_gained_more_than_10_pounds_in_the_past_year\" value=\"1\" data-field-name=\"have_you_lost_or_gained_more_than_10_pounds_in_the_past_year\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-jxtywtiu\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Do you have, or have you had, any disease, condition, or problem not listed above?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\" value=\"0\" data-field-name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\" value=\"1\" data-field-name=\"do_you_have_or_have_you_had_any_disease_condition_or_problem_not__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-xd4dx78k\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Please indicate which of the following you have had or currently have:<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" checked=\"checked\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>AIDS\/HIV Positive <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"1\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Diabetes <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"2\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Mitral Valve Prolapse <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"3\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Anemia <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"4\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Nervous Disorders<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"5\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span> Arthritis\/Rheumatism <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"6\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Difficulty Swallowing <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"7\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Nervousness\/Anxiety <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"8\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Artificial Heart Valve\/Pacemaker <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"9\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Drug Addiction <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"10\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Neurological Disorders <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"11\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Artificial Joints <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"12\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Emphysema <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"13\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Osteoporosis <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"14\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Artificial Prosthesis <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"15\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Epilepsy or Seizures <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"16\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Psychiatric\/Psychological Care<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"17\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Asthma <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"18\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Excessive Bleeding <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"19\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Radiation Therapy <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"20\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Blood Disease <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"21\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Fainting or Dizzy Spells <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"22\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Rheumatic Fever <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"23\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Blood Transfusion <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"24\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Glaucoma <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"25\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Scarlet Fever <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"26\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Bruise Easily <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"27\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Hay Fever <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"28\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Allergies <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"29\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Hives <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"30\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Cancer <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"31\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Tumors <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"32\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Cysts <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"33\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Head Injuries <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"34\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Sinus Trouble <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"35\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Cerebral Palsy <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"36\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Heart Attack <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"37\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Chemotherapy <\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"38\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Congestive Heart Failure<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"39\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Swollen Ankles<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"40\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Chest Pain<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"41\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Heart Murmur<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"42\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Thyroid Disease\/Problems<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"43\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Chicken Pox<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"44\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Hemophilia<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"45\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Tonsillitis<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"46\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Chronic Cough<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"47\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Hepatitis<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"48\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Tuberculosis<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"49\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Cold Sores\/Fever Blisters<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"50\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Herpes<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"51\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Ulcers<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"52\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Congenital Heart Defects<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"53\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>High\/Low Blood Pressure<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"54\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Venereal Disease<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"55\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Contact Lenses<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"56\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Kidney Problems\/Disease<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"57\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Cortisone Medicine<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"58\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Liver Disease\/Jaundice<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\" value=\"59\" data-field-name=\"please_indicate_which_of_the_following_you_have_had_or_currently__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>Other<\/span><\/label><\/div><\/div>\n<\/div>\n<\/div>\n\n\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-7387b849 wp-block-columns-is-layout-flex\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\"><div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-xekz7gqe\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Are you currently nursing?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_currently_nursing\" value=\"0\" data-field-name=\"are_you_currently_nursing\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_currently_nursing\" value=\"1\" data-field-name=\"are_you_currently_nursing\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div><\/div>\n<\/div>\n\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-b8nb2wvd\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Are you pregnant or think you may be pregnant?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_pregnant_or_think_you_may_be_pregnant\" value=\"0\" data-field-name=\"are_you_pregnant_or_think_you_may_be_pregnant\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_pregnant_or_think_you_may_be_pregnant\" value=\"1\" data-field-name=\"are_you_pregnant_or_think_you_may_be_pregnant\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-xbqku9d4\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Are you taking prescription birth control?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_taking_prescription_birth_control\" value=\"0\" data-field-name=\"are_you_taking_prescription_birth_control\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"are_you_taking_prescription_birth_control\" value=\"1\" data-field-name=\"are_you_taking_prescription_birth_control\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-c410krtf\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Do you have any problems related to your menstrual period?<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_any_problems_related_to_your_menstrual_period\" value=\"0\" data-field-name=\"do_you_have_any_problems_related_to_your_menstrual_period\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>YES<\/span><\/label><\/div><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"do_you_have_any_problems_related_to_your_menstrual_period\" value=\"1\" data-field-name=\"do_you_have_any_problems_related_to_your_menstrual_period\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>NO<\/span><\/label><\/div><\/div>\n<\/div>\n\n\n<div style=\"height:60px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\">I have answered all questions to the best of my knowledge and understanding. If further information is needed, I authorize my health care provider or agency to be contacted, and they may release such information. I will notify the doctor of any change in my health or medications.<\/p>\n\n\n\n<div style=\"height:50px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>ACKNOWLEDGMENT AND CONSENT<\/strong><\/p>\n\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-tgra1cpg\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Insurance Payment Authorization: <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"reconocimiento_de_la_autorizacion_de_pago_por_el_seguro\" value=\"0\" data-field-name=\"reconocimiento_de_la_autorizacion_de_pago_por_el_seguro\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I understand the terms<\/span><\/label><\/div><\/div><div class=\"jet-form-builder__desc\"><small>I hereby authorize and direct payment of my dental insurance benefits directly to Mannheim Dental. If my insurance sends payment to me in error, I understand that I am responsible for forwarding said payment immediately. I understand that Mannheim Dental will, as a courtesy, submit a claim to my insurance. If for any reason my insurance denies payment, I am responsible for the full cost of my treatment.<\/small><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-x4wmzuna\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Financial Responsibility Acknowledgment:<\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"financial_responsibility_acknowledgment_br_i_agree_to_be_responsible__\" value=\"0\" data-field-name=\"financial_responsibility_acknowledgment_br_i_agree_to_be_responsible__\"  class=\"jet-form-builder__field radio-field checkradio-field\"><span>I understand the terms and conditions<\/span><\/label><\/div><\/div><div class=\"jet-form-builder__desc\"><small>I agree to be responsible for payment of all services rendered to me or to my dependents. I understand that payment is due at the time of service unless other arrangements have been made. If payments are not made on the agreed dates, I understand that a $15 late fee may be added to my account. I also agree to notify Mannheim Dental of any change of address, phone number, or insurance within 30 days of such change. If I fail to meet these requirements, I authorize the use of all appropriate means, including credit history records, to locate my new address for collection purposes.<\/small><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-kj2z859g\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Notice of Privacy Practices <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"notice_of_privacy_practices\" value=\"0\" data-field-name=\"notice_of_privacy_practices\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I understand the terms and conditions<\/span><\/label><\/div><\/div><div class=\"jet-form-builder__desc\"><small>I acknowledge that I have received information about the practice's privacy practices, which describes how the practice may use and disclose my health information for treatment, payment, health care operations, and other permitted uses and disclosures described therein. I understand that I may contact the privacy officer designated in the notice if I have any questions or complaints. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice's Notice of Privacy Practices.<\/small><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-ydd4u1t2\">\n<div class=\"jet-form-builder__label\">\r\n<div class=\"jet-form-builder__label-text\">Missed or Canceled Appointments <span class=\"jet-form-builder__required\">*<\/span><\/div><\/div><div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"missed_or_canceled_appointments\" value=\"0\" data-field-name=\"missed_or_canceled_appointments\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I understand the terms and conditions<\/span><\/label><\/div><\/div><div class=\"jet-form-builder__desc\"><small>If you are unable to attend your scheduled appointment, Mannheim Dental requires 24 hours' notice; otherwise, a $50 fee will be added to your account, and payment is due immediately. After three canceled or missed appointments without notice, Mannheim Dental reserves the right to terminate the patient\/doctor relationship.<\/small><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-radio-field wp-block-jet-forms-radio-field cb-azmvrbf5\">\n<div class=\"jet-form-builder__fields-group checkradio-wrap\" data-jfb-sync><div class=\"jet-form-builder__field-wrap radio-wrap checkradio-wrap\"><label class=\"jet-form-builder__field-label for-radio\">\n<input type=\"radio\" name=\"i_acknowledge_that_i_have_received_and_read_the_dental_materials__\" value=\"0\" data-field-name=\"i_acknowledge_that_i_have_received_and_read_the_dental_materials__\"  class=\"jet-form-builder__field radio-field checkradio-field\" required=\"required\"><span>I acknowledge that I have received and read the Dental Materials Fact Sheet before beginning treatment at Mannheim Dental.<\/span><\/label><\/div><\/div>\n<\/div>\n\n<div  class=\"jet-form-builder-row field-type-submit-field cb-je11322l\" >\n\t<div data-type=\"submit\" class=\"jet-form-builder__action-button-wrapper jet-form-builder__submit-wrap\">\n\t<button class=\"jet-form-builder__action-button jet-form-builder__submit submit-type-reload\" type=\"submit\">Request appointment<\/button>\n\t<\/div>\n\t\n<\/div>\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\t<div class=\"jet-form-builder-messages-wrap\" data-form-id=\"1133\"><\/div>\n<\/form>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-ff31edb e-con e-atomic-element e-flexbox-base e-default-div e-ff31edb-4c93161 \" data-id=\"ff31edb\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"ff31edb\" data-e-type=\"e-flexbox\" data-id=\"ff31edb\">\n    \n<\/div>\n\n<\/div>\n\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Request an appointment Fill out the quick form below and our team will confirm your appointment by phone. New patients always welcome. FULL NAME * PHONE NUMBER EMAIL PREFERRED DATE DATE OF BIRTH PREFERRED TIME NEW PATIENT EXISTING PATIENT FIRST NAME MIDDLE NAME ADDRESS CITY STATE ZIP CODE GENDER MALEFEMALENOT SPECIFIEDOTHER What pronouns do you [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-120","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages\/120","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/comments?post=120"}],"version-history":[{"count":100,"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages\/120\/revisions"}],"predecessor-version":[{"id":1251,"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/pages\/120\/revisions\/1251"}],"wp:attachment":[{"href":"https:\/\/mannheimdental.com\/es\/wp-json\/wp\/v2\/media?parent=120"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}