{"id":646,"date":"2025-02-10T17:50:28","date_gmt":"2025-02-10T17:50:28","guid":{"rendered":"https:\/\/lefnyplasticsurgery.com\/?page_id=646"},"modified":"2026-03-04T23:31:02","modified_gmt":"2026-03-04T23:31:02","slug":"formulario-cirugia-plastica","status":"publish","type":"page","link":"https:\/\/lefnyplasticsurgery.com\/en\/formulario-cirugia-plastica\/","title":{"rendered":"Plastic Surgery Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"646\" class=\"elementor elementor-646\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3a9b202 e-flex e-con-boxed e-con e-parent\" data-id=\"3a9b202\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5712db4 elementor-widget-tablet__width-initial elementor-widget elementor-widget-heading\" data-id=\"5712db4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Agenda tu consulta gratuita para tu Cirug\u00eda Plastica<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-77a7bde elementor-button-align-center elementor-widget-mobile__width-inherit elementor-widget elementor-widget-form\" data-id=\"77a7bde\" data-element_type=\"widget\" data-e-type=\"widget\" id=\"form_cirugia_plastica\" data-settings=\"{&quot;step_next_label&quot;:&quot;Siguiente&quot;,&quot;step_previous_label&quot;:&quot;Anterior&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-no-translation=\"\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<style>.elementor-element-77a7bde{display:none !important}<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c634ac0 elementor-button-align-center elementor-widget-mobile__width-inherit elementor-widget elementor-widget-form\" data-id=\"c634ac0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Siguiente&quot;,&quot;step_previous_label&quot;:&quot;Anterior&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Nuevo formulario\" aria-label=\"Nuevo formulario\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"646\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"c634ac0\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Lefny Plastic Surgery\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_448ded3 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-name elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre y apellido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Nombre y apellido\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Correo electr\u00f3nico\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_bb0996f elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bb0996f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_bb0996f]\" id=\"form-field-field_bb0996f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ej:+1 555 555 555\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d21e5b6 elementor-col-33 elementor-sm-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d21e5b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d21e5b6]\" id=\"form-field-field_d21e5b6\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Ciudad\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a1897a6 elementor-col-33 elementor-sm-60 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a1897a6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPa\u00eds de Residencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a1897a6]\" id=\"form-field-field_a1897a6\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\">Selecciona tu pa\u00eds<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Afghanistan\">Afghanistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aland Islands\">Aland Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Albania\">Albania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Algeria\">Algeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Samoa\">American Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Andorra\">Andorra<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Angola\">Angola<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Anguilla\">Anguilla<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Antarctica\">Antarctica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Argentina\">Argentina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Armenia\">Armenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aruba\">Aruba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Australia\">Australia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Austria\">Austria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Azerbaijan\">Azerbaijan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahamas\">Bahamas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bahrain\">Bahrain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bangladesh\">Bangladesh<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Barbados\">Barbados<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belarus\">Belarus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belgium\">Belgium<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Belize\">Belize<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Benin\">Benin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bermuda\">Bermuda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bhutan\">Bhutan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bolivia\">Bolivia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Botswana\">Botswana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bouvet 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value=\"Chad\">Chad<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Chile\">Chile<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"China\">China<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Christmas Island\">Christmas Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colombia\">Colombia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Comoros\">Comoros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Congo\">Congo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Congo, The Democratic Republic of the\">Congo, The Democratic Republic of the<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cook Islands\">Cook Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Costa Rica\">Costa Rica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cote D&quot;Ivoire\">Cote D&quot;Ivoire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Croatia\">Croatia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuba\">Cuba<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cyprus\">Cyprus<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Czech Republic\">Czech Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Denmark\">Denmark<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Djibouti\">Djibouti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominica\">Dominica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dominican Republic\">Dominican Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ecuador\">Ecuador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Egypt\">Egypt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"El Salvador\">El Salvador<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eritrea\">Eritrea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Estonia\">Estonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ethiopia\">Ethiopia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Falkland Islands (Malvinas)\">Falkland Islands (Malvinas)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Faroe Islands\">Faroe Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Fiji\">Fiji<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Finland\">Finland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"France\">France<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"French Guiana\">French Guiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"French Polynesia\">French Polynesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"French Southern Territories\">French Southern Territories<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gabon\">Gabon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gambia\">Gambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Germany\">Germany<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ghana\">Ghana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gibraltar\">Gibraltar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greece\">Greece<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Greenland\">Greenland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grenada\">Grenada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guadeloupe\">Guadeloupe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guam\">Guam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guatemala\">Guatemala<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guernsey\">Guernsey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea\">Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guyana\">Guyana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Haiti\">Haiti<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heard Island and McDonald Islands\">Heard Island and McDonald Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holy See (Vatican City State)\">Holy See (Vatican City State)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Honduras\">Honduras<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hong Kong\">Hong Kong<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hungary\">Hungary<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iceland\">Iceland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"India\">India<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indonesia\">Indonesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iran, Islamic Republic Of\">Iran, Islamic Republic Of<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iraq\">Iraq<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ireland\">Ireland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Isle of Man\">Isle of Man<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Israel\">Israel<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Italy\">Italy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jamaica\">Jamaica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Japan\">Japan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jersey\">Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Jordan\">Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kazakhstan\">Kazakhstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kenya\">Kenya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kiribati\">Kiribati<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Korea People&#039;s Democratic Republic\">Korea People&#039;s Democratic Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Republic of Korea\">Republic of Korea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kosovo\">Kosovo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kuwait\">Kuwait<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kyrgyzstan\">Kyrgyzstan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Latvia\">Latvia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lebanon\">Lebanon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lesotho\">Lesotho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liberia\">Liberia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Libyan Arab Jamahiriya\">Libyan Arab Jamahiriya<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Liechtenstein\">Liechtenstein<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lithuania\">Lithuania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Luxembourg\">Luxembourg<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Macao\">Macao<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Macedonia\">North Macedonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Madagascar\">Madagascar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malawi\">Malawi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malaysia\">Malaysia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maldives\">Maldives<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mali\">Mali<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Malta\">Malta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Marshall Islands\">Marshall Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Martinique\">Martinique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritania\">Mauritania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mauritius\">Mauritius<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mayotte\">Mayotte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mexico\">Mexico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Federated States of Micronesia\">Federated States of Micronesia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moldova, Republic of\">Moldova, Republic of<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Monaco\">Monaco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mongolia\">Mongolia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montenegro\">Montenegro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montserrat\">Montserrat<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Morocco\">Morocco<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mozambique\">Mozambique<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Myanmar\">Myanmar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Namibia\">Namibia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nauru\">Nauru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nepal\">Nepal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Netherlands\">Netherlands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Netherlands Antilles\">Netherlands Antilles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Caledonia\">New Caledonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Zealand\">New Zealand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nicaragua\">Nicaragua<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Niger\">Niger<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nigeria\">Nigeria<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Niue\">Niue<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Norfolk Island\">Norfolk Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Norway\">Norway<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oman\">Oman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pakistan\">Pakistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palau\">Palau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Palestinian Territory, Occupied\">Palestinian Territory, Occupied<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Panama\">Panama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Papua New Guinea\">Papua New Guinea<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Paraguay\">Paraguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Peru\">Peru<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Philippines\">Philippines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pitcairn\">Pitcairn<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Poland\">Poland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Portugal\">Portugal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Puerto Rico\">Puerto Rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Qatar\">Qatar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Reunion\">Reunion<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Romania\">Romania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Russian Federation\">Russian Federation<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rwanda\">Rwanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Helena\">Saint Helena<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Lucia\">Saint Lucia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Martin\">Saint Martin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Samoa\">Samoa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"San Marino\">San Marino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Senegal\">Senegal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Serbia\">Serbia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Seychelles\">Seychelles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sierra Leone\">Sierra Leone<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Singapore\">Singapore<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sint Maarten\">Sint Maarten<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovakia\">Slovakia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Slovenia\">Slovenia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Solomon Islands\">Solomon Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Somalia\">Somalia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Africa\">South Africa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Georgia and the South Sandwich Islands\">South Georgia and the South Sandwich Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spain\">Spain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sri Lanka\">Sri Lanka<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sudan\">Sudan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Suriname\">Suriname<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Svalbard and Jan Mayen\">Svalbard and Jan Mayen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eswatini\">Eswatini<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sweden\">Sweden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Switzerland\">Switzerland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Syrian Arab Republic\">Syrian Arab Republic<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taiwan\">Taiwan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tajikistan\">Tajikistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tanzania, United Republic of\">Tanzania, United Republic of<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Thailand\">Thailand<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Timor-Leste\">Timor-Leste<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Togo\">Togo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tokelau\">Tokelau<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tonga\">Tonga<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tunisia\">Tunisia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkey\">Turkey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turkmenistan\">Turkmenistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tuvalu\">Tuvalu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uganda\">Uganda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"UK\">UK<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ukraine\">Ukraine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United States\">United States<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"United States Minor Outlying Islands\">United States Minor Outlying Islands<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uruguay\">Uruguay<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uzbekistan\">Uzbekistan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vanuatu\">Vanuatu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Venezuela\">Venezuela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vietnam\">Vietnam<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, British\">Virgin Islands, British<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wallis and Futuna\">Wallis and Futuna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Western Sahara\">Western Sahara<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yemen\">Yemen<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zambia\">Zambia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Zimbabwe\">Zimbabwe<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_791948d elementor-col-33 elementor-sm-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_791948d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEdad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_791948d]\" id=\"form-field-field_791948d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Edad\" required=\"required\" min=\"18\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ca0d19 elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ca0d19\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPeso (Indicar m\u00e9trica)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ca0d19]\" id=\"form-field-field_3ca0d19\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Indica la m\u00e9trica\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a2fba59 elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a2fba59\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAltura (Indicar m\u00e9trica)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a2fba59]\" id=\"form-field-field_a2fba59\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" placeholder=\"Indicar m\u00e9trica\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_83041c2 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_83041c2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfPorque v\u00eda te enteraste de nosotros?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Instagram\" id=\"form-field-field_83041c2-0\" name=\"form_fields[field_83041c2]\" required=\"required\"> <label for=\"form-field-field_83041c2-0\">Instagram<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Tiktok\" id=\"form-field-field_83041c2-1\" name=\"form_fields[field_83041c2]\" required=\"required\"> <label for=\"form-field-field_83041c2-1\">Tiktok<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Google\" id=\"form-field-field_83041c2-2\" name=\"form_fields[field_83041c2]\" required=\"required\"> <label for=\"form-field-field_83041c2-2\">Google<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Youtube\" id=\"form-field-field_83041c2-3\" name=\"form_fields[field_83041c2]\" required=\"required\"> <label for=\"form-field-field_83041c2-3\">Youtube<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Recomendaci\u00f3n\" id=\"form-field-field_83041c2-4\" name=\"form_fields[field_83041c2]\" required=\"required\"> <label for=\"form-field-field_83041c2-4\">Recomendaci\u00f3n<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_72c8414 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_72c8414\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tQue procedimiento deseas realizarte?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Abdominoplastia lipo bbl\" id=\"form-field-field_72c8414-0\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-0\">Abdominoplastia lipo bbl<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lipo bbl\" id=\"form-field-field_72c8414-1\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-1\">Lipo bbl<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lipo bbl y senos\" id=\"form-field-field_72c8414-2\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-2\">Lipo bbl y senos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lipo bbl senos con implantes\" id=\"form-field-field_72c8414-3\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-3\">Lipo bbl senos con implantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Levantamiento de senos con implantes\" id=\"form-field-field_72c8414-4\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-4\">Levantamiento de senos con implantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Levantamiento de senos sin implantes\" id=\"form-field-field_72c8414-5\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-5\">Levantamiento de senos sin implantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Facelift\" id=\"form-field-field_72c8414-6\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-6\">Facelift<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Neck lift\" id=\"form-field-field_72c8414-7\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-7\">Neck lift<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Lipo papada\" id=\"form-field-field_72c8414-8\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-8\">Lipo papada<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Braquioplastia\" id=\"form-field-field_72c8414-9\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-9\">Braquioplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cruroplastia\" id=\"form-field-field_72c8414-10\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-10\">Cruroplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Abdominoplastia y senos con implantes\" id=\"form-field-field_72c8414-11\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-11\">Abdominoplastia y senos con implantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Abdominoplastia y reducci\u00f3n de senos\" id=\"form-field-field_72c8414-12\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-12\">Abdominoplastia y reducci\u00f3n de senos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Extracci\u00f3n de biopol\u00edmeros\" id=\"form-field-field_72c8414-13\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-13\">Extracci\u00f3n de biopol\u00edmeros<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Explantaci\u00f3n mamaria\" id=\"form-field-field_72c8414-14\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-14\">Explantaci\u00f3n mamaria<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rinoplastia\" id=\"form-field-field_72c8414-15\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-15\">Rinoplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Otoplastia\" id=\"form-field-field_72c8414-16\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-16\">Otoplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Butt lift\" id=\"form-field-field_72c8414-17\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-17\">Butt lift<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fleur the liz abdominoplastia\" id=\"form-field-field_72c8414-18\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-18\">Fleur the liz abdominoplastia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Blefaroplastia\" id=\"form-field-field_72c8414-19\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-19\">Blefaroplastia<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_2441084 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2441084\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDonde quieres hacer tu cirug\u00eda?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Rep\u00fablica Dominicana\" id=\"form-field-field_2441084-0\" name=\"form_fields[field_2441084]\" required=\"required\"> <label for=\"form-field-field_2441084-0\">Rep\u00fablica Dominicana<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Colombia\" id=\"form-field-field_2441084-1\" name=\"form_fields[field_2441084]\" required=\"required\"> <label for=\"form-field-field_2441084-1\">Colombia<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_107a576 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_107a576\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEscribe 3 posibles fechas para tu cirug\u00eda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_107a576]\" id=\"form-field-field_107a576\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-elige_un_doctor elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-elige_un_doctor\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tElige un doctor\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[elige_un_doctor]\" id=\"form-field-elige_un_doctor\" class=\"elementor-field-textual elementor-size-sm\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Manuel Peralta\">Dr. Manuel Peralta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Givanny P\u00e9rez\">Dr. Givanny P\u00e9rez<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Jos\u00e9 Mora\">Dr. Jos\u00e9 Mora<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Yusef Marrero\">Dr. Yusef Marrero<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Jos\u00e9 Luis Mej\u00eda\">Dr. Jos\u00e9 Luis Mej\u00eda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Primavera Quirot\">Dra. Primavera Quirot<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Toribio\">Dr. Toribio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Glorinil Mercedes\">Dra. Glorinil Mercedes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Yili De los Santos\">Dra. Yili De los Santos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Gustavo Alm\u00e1nzar\">Dr. Gustavo Alm\u00e1nzar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Dur\u00e1n\">Dr. Dur\u00e1n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Jos\u00e9 Luis Plaza\">Dr. Jos\u00e9 Luis Plaza<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Walkiris Robles\">Dra. Walkiris Robles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Santos Espinal\">Dr. Santos Espinal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Francisco Rodr\u00edguez\">Dr. Francisco Rodr\u00edguez<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Danivel C\u00e9spedes\">Dra. Danivel C\u00e9spedes<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Ana Carpio\">Dra. Ana Carpio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Mart\u00edn Robles\">Dr. Mart\u00edn Robles<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dra. Mar\u00eda Fernanda\">Dra. Mar\u00eda Fernanda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Jes\u00fas Abreu\">Dr. Jes\u00fas Abreu<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Manuel Torreira\">Dr. Manuel Torreira<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Gebal Matos\">Dr. Gebal Matos<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Dr. Emir Duquela\">Dr. Emir Duquela<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Otro\">Otro<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-nombre_doctor_manual elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-nombre_doctor_manual\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEscribe el nombre del doctor\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[nombre_doctor_manual]\" id=\"form-field-nombre_doctor_manual\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-doctor_final elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-doctor_final\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre doctor\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[doctor_final]\" id=\"form-field-doctor_final\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-tienes_hijos elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tienes_hijos\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes Hijos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-tienes_hijos-0\" name=\"form_fields[tienes_hijos]\" required=\"required\"> <label for=\"form-field-tienes_hijos-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-tienes_hijos-1\" name=\"form_fields[tienes_hijos]\" required=\"required\"> <label for=\"form-field-tienes_hijos-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-cesareas elementor-col-50 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-cesareas\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCes\u00e1reas?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"S\u00ed\" id=\"form-field-cesareas-0\" name=\"form_fields[cesareas]\"> <label for=\"form-field-cesareas-0\">S\u00ed<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-cesareas-1\" name=\"form_fields[cesareas]\"> <label for=\"form-field-cesareas-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_1d803b2 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_dba313b elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dba313b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfFumas? Indica con que frecuencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nunca\" id=\"form-field-field_dba313b-0\" name=\"form_fields[field_dba313b]\" required=\"required\"> <label for=\"form-field-field_dba313b-0\">Nunca<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ocasionalmente\" id=\"form-field-field_dba313b-1\" name=\"form_fields[field_dba313b]\" required=\"required\"> <label for=\"form-field-field_dba313b-1\">Ocasionalmente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Frecuentemente\" id=\"form-field-field_dba313b-2\" name=\"form_fields[field_dba313b]\" required=\"required\"> <label for=\"form-field-field_dba313b-2\">Frecuentemente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Diario\" id=\"form-field-field_dba313b-3\" name=\"form_fields[field_dba313b]\" required=\"required\"> <label for=\"form-field-field_dba313b-3\">Diario<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_29cf7a1 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_29cf7a1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfBebes alcohol? Indica con que frecuencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nunca\" id=\"form-field-field_29cf7a1-0\" name=\"form_fields[field_29cf7a1]\" required=\"required\"> <label for=\"form-field-field_29cf7a1-0\">Nunca<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ocasionalmente\" id=\"form-field-field_29cf7a1-1\" name=\"form_fields[field_29cf7a1]\" required=\"required\"> <label for=\"form-field-field_29cf7a1-1\">Ocasionalmente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Frecuentemente\" id=\"form-field-field_29cf7a1-2\" name=\"form_fields[field_29cf7a1]\" required=\"required\"> <label for=\"form-field-field_29cf7a1-2\">Frecuentemente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Diario\" id=\"form-field-field_29cf7a1-3\" name=\"form_fields[field_29cf7a1]\" required=\"required\"> <label for=\"form-field-field_29cf7a1-3\">Diario<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4920b6c elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4920b6c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfDrogas? Indica con que frecuencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Nunca\" id=\"form-field-field_4920b6c-0\" name=\"form_fields[field_4920b6c]\" required=\"required\"> <label for=\"form-field-field_4920b6c-0\">Nunca<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ocasionalmente\" id=\"form-field-field_4920b6c-1\" name=\"form_fields[field_4920b6c]\" required=\"required\"> <label for=\"form-field-field_4920b6c-1\">Ocasionalmente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Frecuentemente\" id=\"form-field-field_4920b6c-2\" name=\"form_fields[field_4920b6c]\" required=\"required\"> <label for=\"form-field-field_4920b6c-2\">Frecuentemente<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Diario\" id=\"form-field-field_4920b6c-3\" name=\"form_fields[field_4920b6c]\" required=\"required\"> <label for=\"form-field-field_4920b6c-3\">Diario<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_29e60c8 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-tienes_enfermedades elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tienes_enfermedades\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes enfermedades?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-tienes_enfermedades-0\" name=\"form_fields[tienes_enfermedades]\" required=\"required\"> <label for=\"form-field-tienes_enfermedades-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-tienes_enfermedades-1\" name=\"form_fields[tienes_enfermedades]\" required=\"required\"> <label for=\"form-field-tienes_enfermedades-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-que_enfermedades_tienes elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-que_enfermedades_tienes\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQue enfermedades tienes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[que_enfermedades_tienes]\" id=\"form-field-que_enfermedades_tienes\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-estas_tomando_medicamentos elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-estas_tomando_medicamentos\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEstas tomando medicamentos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-estas_tomando_medicamentos-0\" name=\"form_fields[estas_tomando_medicamentos]\" required=\"required\"> <label for=\"form-field-estas_tomando_medicamentos-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-estas_tomando_medicamentos-1\" name=\"form_fields[estas_tomando_medicamentos]\" required=\"required\"> <label for=\"form-field-estas_tomando_medicamentos-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-que_medicamentos_tomas elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-que_medicamentos_tomas\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQu\u00e9 medicamentos est\u00e1s tomando?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[que_medicamentos_tomas]\" id=\"form-field-que_medicamentos_tomas\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-estas_tomando_suplementos elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-estas_tomando_suplementos\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1s tomando suplementos o quemadores de grasa? \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-estas_tomando_suplementos-0\" name=\"form_fields[estas_tomando_suplementos]\" required=\"required\"> <label for=\"form-field-estas_tomando_suplementos-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-estas_tomando_suplementos-1\" name=\"form_fields[estas_tomando_suplementos]\" required=\"required\"> <label for=\"form-field-estas_tomando_suplementos-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-que_suplementos_tomas elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-que_suplementos_tomas\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQue suplementos o quemadores de grasa estas tomando?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[que_suplementos_tomas]\" id=\"form-field-que_suplementos_tomas\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-te_has_realizado_cirugia elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-te_has_realizado_cirugia\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTe haz realizado alguna cirug\u00eda?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-te_has_realizado_cirugia-0\" name=\"form_fields[te_has_realizado_cirugia]\" required=\"required\"> <label for=\"form-field-te_has_realizado_cirugia-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-te_has_realizado_cirugia-1\" name=\"form_fields[te_has_realizado_cirugia]\" required=\"required\"> <label for=\"form-field-te_has_realizado_cirugia-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-que_cirugia_te_has_realizado elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-que_cirugia_te_has_realizado\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQue cirug\u00eda te haz realizado?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[que_cirugia_te_has_realizado]\" id=\"form-field-que_cirugia_te_has_realizado\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-tienes_alergia elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tienes_alergia\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes alguna alergia?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-tienes_alergia-0\" name=\"form_fields[tienes_alergia]\" required=\"required\"> <label for=\"form-field-tienes_alergia-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-tienes_alergia-1\" name=\"form_fields[tienes_alergia]\" required=\"required\"> <label for=\"form-field-tienes_alergia-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-que_alergia_tienes elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-que_alergia_tienes\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfQue alergia tienes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[que_alergia_tienes]\" id=\"form-field-que_alergia_tienes\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_da04d1d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a6f22e5 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6f22e5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEres HIV POSITIVO?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-field_a6f22e5-0\" name=\"form_fields[field_a6f22e5]\" required=\"required\"> <label for=\"form-field-field_a6f22e5-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a6f22e5-1\" name=\"form_fields[field_a6f22e5]\" required=\"required\"> <label for=\"form-field-field_a6f22e5-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_08f6ffa elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_08f6ffa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes Lupus?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-field_08f6ffa-0\" name=\"form_fields[field_08f6ffa]\" required=\"required\"> <label for=\"form-field-field_08f6ffa-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_08f6ffa-1\" name=\"form_fields[field_08f6ffa]\" required=\"required\"> <label for=\"form-field-field_08f6ffa-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_aea7372 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aea7372\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes Hepatitis B o C?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Si\" id=\"form-field-field_aea7372-0\" name=\"form_fields[field_aea7372]\" required=\"required\"> <label for=\"form-field-field_aea7372-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_aea7372-1\" name=\"form_fields[field_aea7372]\" required=\"required\"> <label for=\"form-field-field_aea7372-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-upload elementor-field-group elementor-column elementor-field-group-field_f0c64ed elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f0c64ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEnviar fotos de frente, lado y espalda y una sentada\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"file\" name=\"form_fields[field_f0c64ed][]\" id=\"form-field-field_f0c64ed\" class=\"elementor-field elementor-size-sm  elementor-upload-field\" required=\"required\" multiple=\"multiple\" data-maxsize=\"50\" data-maxsize-message=\"This file exceeds the maximum allowed size.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_8dda30f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_8dda30f]\" id=\"form-field-field_8dda30f\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_8dda30f\">Al enviar este formulario, aceptas que tus datos sean procesados a trav\u00e9s de sistemas externos conforme a nuestra <a href=\"\/politica-de-privacidad\/\" target=\"_blank\">Pol\u00edtica de Privacidad<\/a><\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_c0b93a7 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_c0b93a7]\" id=\"form-field-field_c0b93a7\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_c0b93a7\">I consent to receive marketing text messages from Lefny Plastic Surgery at the number provided. Message frequency may vary. Message and data rates may apply. Text HELP for support or STOP to unsubscribe.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_2dc625d elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_2dc625d]\" id=\"form-field-field_2dc625d\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_2dc625d\">I consent to receive informational messages from Lefny Plastic Surgery regarding my surgery coordination, appointment reminders, and service updates. Message frequency varies based on activity. Message and data rates may apply. Text HELP for support or STOP to cancel.<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0817339 elementor-widget elementor-widget-html\" data-id=\"0817339\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\r\njQuery(document).ready(function($) {\r\n    \/\/ Pares de campos desencadenantes y condicionales\r\n    var conditions = [\r\n        { trigger: '[name=\"form_fields[tienes_hijos]\"]', conditional: '[name=\"form_fields[cesareas]\"]' },\r\n        { trigger: '[name=\"form_fields[tienes_enfermedades]\"]', conditional: '[name=\"form_fields[que_enfermedades_tienes]\"]' },\r\n        { trigger: '[name=\"form_fields[estas_tomando_medicamentos]\"]', conditional: '[name=\"form_fields[que_medicamentos_tomas]\"]' },\r\n        { trigger: '[name=\"form_fields[estas_tomando_suplementos]\"]', conditional: '[name=\"form_fields[que_suplementos_tomas]\"]' },\r\n        { trigger: '[name=\"form_fields[te_has_realizado_cirugia]\"]', conditional: '[name=\"form_fields[que_cirugia_te_has_realizado]\"]' },\r\n        { trigger: '[name=\"form_fields[tienes_alergia]\"]', conditional: '[name=\"form_fields[que_alergia_tienes]\"]' },\r\n        { trigger: '[name=\"form_fields[elige_un_doctor]\"]', conditional: '[name=\"form_fields[nombre_doctor_manual]\"]' } \/\/ NUEVA CONDICI\u00d3N\r\n    ];\r\n\r\n    \/\/ Ocultar y deshabilitar todos los campos condicionales al cargar la p\u00e1gina\r\n    conditions.forEach(function(pair) {\r\n        var conditional = $(pair.conditional);\r\n        if (conditional.length) {\r\n            var fieldGroup = conditional.closest('.elementor-field-group');\r\n            fieldGroup.css({\r\n                'position': 'absolute',\r\n                'visibility': 'hidden',\r\n                'overflow': 'hidden',\r\n                'height': '0',\r\n                'width': '0'\r\n            });\r\n            conditional.removeAttr('required');\r\n            conditional.prop('disabled', true);\r\n        }\r\n    });\r\n\r\n    \/\/ Funci\u00f3n para manejar la l\u00f3gica condicional\r\n    function toggleConditional(trigger, conditional) {\r\n        var value = trigger.val() ? trigger.val().toLowerCase() : '';\r\n        var fieldGroup = conditional.closest('.elementor-field-group');\r\n\r\n        \/\/ Mostrar si el valor es s\u00ed\/s\u00ed\/yes\/yeah o \"otro\"\r\n        if (['s\u00ed', 'si', 'yes', 'yeah', 'otro'].includes(value)) {\r\n            fieldGroup.css({\r\n                'position': 'relative',\r\n                'visibility': 'visible',\r\n                'overflow': 'visible',\r\n                'height': '',\r\n                'width': ''\r\n            });\r\n            conditional.attr('required', 'required');\r\n            conditional.prop('disabled', false);\r\n            conditional.trigger('change');\r\n        } else {\r\n            fieldGroup.css({\r\n                'position': 'absolute',\r\n                'visibility': 'hidden',\r\n                'overflow': 'hidden',\r\n                'height': '0',\r\n                'width': '0'\r\n            });\r\n            conditional.removeAttr('required');\r\n            conditional.prop('disabled', true);\r\n            conditional.trigger('change');\r\n        }\r\n    }\r\n\r\n    \/\/ Aplicar l\u00f3gica condicional al cambiar\r\n    conditions.forEach(function(pair) {\r\n        var trigger = $(pair.trigger);\r\n        var conditional = $(pair.conditional);\r\n        if (trigger.length && conditional.length) {\r\n            trigger.on('change', function() {\r\n                toggleConditional($(this), conditional);\r\n            });\r\n\r\n            \/\/ Ejecutar al cargar (por si ya hay valores seleccionados)\r\n            toggleConditional(trigger, conditional);\r\n        }\r\n    });\r\n});\r\n<\/script>\r\n\r\n<script>\r\njQuery(document).ready(function($) {\r\n    function actualizarDoctorFinal() {\r\n        var seleccion = $('[name=\"form_fields[elige_un_doctor]\"]').val();\r\n        var manual = $('[name=\"form_fields[nombre_doctor_manual]\"]').val();\r\n        var final = (seleccion && seleccion.toLowerCase() === 'otro') ? manual : seleccion;\r\n\r\n        $('[name=\"form_fields[doctor_final]\"]').val(final);\r\n    }\r\n\r\n    \/\/ Escucha cambios en ambos campos\r\n    $('[name=\"form_fields[elige_un_doctor]\"]').on('change', function() {\r\n        actualizarDoctorFinal();\r\n    });\r\n\r\n    \/\/ Escucha escritura en el campo manual (input)\r\n    $('[name=\"form_fields[nombre_doctor_manual]\"]').on('input change blur', function() {\r\n        actualizarDoctorFinal();\r\n    });\r\n\r\n    \/\/ Ejecutar al cargar la p\u00e1gina\r\n    setTimeout(actualizarDoctorFinal, 300);\r\n});\r\n<\/script>\r\n\r\n\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a796d67 elementor-widget elementor-widget-html\" data-id=\"a796d67\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<script>\r\ndocument.addEventListener(\"DOMContentLoaded\", function () {\r\n    const fileInput = document.querySelector(\"input[type='file']\");\r\n    const previewContainer = document.createElement(\"div\");\r\n    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