{"id":785,"date":"2025-02-11T16:01:51","date_gmt":"2025-02-11T16:01:51","guid":{"rendered":"https:\/\/lefnyplasticsurgery.com\/?page_id=785"},"modified":"2026-03-04T23:32:18","modified_gmt":"2026-03-04T23:32:18","slug":"formulario-cirugia-bariatrica","status":"publish","type":"page","link":"https:\/\/lefnyplasticsurgery.com\/en\/formulario-cirugia-bariatrica\/","title":{"rendered":"Bariatric Surgery Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"785\" class=\"elementor elementor-785\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-429f73a e-flex e-con-boxed e-con e-parent\" data-id=\"429f73a\" 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-f0d71a0 elementor-widget-tablet__width-initial elementor-widget elementor-widget-heading\" data-id=\"f0d71a0\" 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 Bari\u00e1trica<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-65b98fa elementor-button-align-center elementor-widget-mobile__width-inherit elementor-widget elementor-widget-form\" data-id=\"65b98fa\" 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-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-65b98fa{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-4f29779 elementor-button-align-center elementor-widget-mobile__width-inherit elementor-widget elementor-widget-form\" data-id=\"4f29779\" 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=\"785\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"4f29779\"\/>\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_2f53793 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_2f53793\" 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_2f53793]\" id=\"form-field-field_2f53793\" 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=\"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 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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=\"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-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=\"Manga g\u00e1strica\" id=\"form-field-field_72c8414-0\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-0\">Manga g\u00e1strica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Manga endosc\u00f3pica\" id=\"form-field-field_72c8414-1\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-1\">Manga endosc\u00f3pica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Bypass g\u00e1strico\" id=\"form-field-field_72c8414-2\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-2\">Bypass g\u00e1strico<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Plicatura g\u00e1strica\" id=\"form-field-field_72c8414-3\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-3\">Plicatura g\u00e1strica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Bal\u00f3n g\u00e1strico\" id=\"form-field-field_72c8414-4\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-4\">Bal\u00f3n g\u00e1strico<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Manga g\u00e1strica\" id=\"form-field-field_72c8414-5\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-5\">Manga g\u00e1strica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Manga endosc\u00f3pica \" id=\"form-field-field_72c8414-6\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-6\">Manga endosc\u00f3pica <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Bypass g\u00e1strico \" id=\"form-field-field_72c8414-7\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-7\">Bypass g\u00e1strico <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Bal\u00f3n g\u00e1strico \" id=\"form-field-field_72c8414-8\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-8\">Bal\u00f3n g\u00e1strico <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Revisi\u00f3n de cirug\u00eda bari\u00e1trica\" id=\"form-field-field_72c8414-9\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-9\">Revisi\u00f3n de cirug\u00eda bari\u00e1trica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Retiro de bal\u00f3n g\u00e1strico \" id=\"form-field-field_72c8414-10\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-10\">Retiro de bal\u00f3n g\u00e1strico <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Remoci\u00f3n de bal\u00f3n g\u00e1strico\" id=\"form-field-field_72c8414-11\" name=\"form_fields[field_72c8414][]\"> <label for=\"form-field-field_72c8414-11\">Remoci\u00f3n de bal\u00f3n g\u00e1strico<\/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_2484e4c 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_2484e4c\" 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_2484e4c-0\" name=\"form_fields[field_2484e4c]\" required=\"required\"> <label for=\"form-field-field_2484e4c-0\">Rep\u00fablica Dominicana<\/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_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\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_2441084]\" id=\"form-field-field_2441084\" 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-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-checkbox elementor-field-group elementor-column elementor-field-group-field_382da0e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_382da0e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfHas sido diagnosticado con alguna de estas condiciones digestivas?\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=\"Reflujo g\u00e1strico cr\u00f3nico\" id=\"form-field-field_382da0e-0\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-0\">Reflujo g\u00e1strico cr\u00f3nico<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hernia hiatal\" id=\"form-field-field_382da0e-1\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-1\">Hernia hiatal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Estenosis esof\u00e1gica\" id=\"form-field-field_382da0e-2\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-2\">Estenosis esof\u00e1gica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Divert\u00edculos\" id=\"form-field-field_382da0e-3\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-3\">Divert\u00edculos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"\u00dalceras g\u00e1stricas o duodenales\" id=\"form-field-field_382da0e-4\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-4\">\u00dalceras g\u00e1stricas o duodenales<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ninguna de las anteriores\" id=\"form-field-field_382da0e-5\" name=\"form_fields[field_382da0e][]\"> <label for=\"form-field-field_382da0e-5\">Ninguna de las anteriores<\/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_0b6af63 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0b6af63\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfHas tenido alguna de estas cirug\u00edas o procedimientos m\u00e9dicos importantes?\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=\"Apendicitis perforada\" id=\"form-field-field_0b6af63-0\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-0\">Apendicitis perforada<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ces\u00e1reas (3 o m\u00e1s)\" id=\"form-field-field_0b6af63-1\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-1\">Ces\u00e1reas (3 o m\u00e1s)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Laparotom\u00eda\" id=\"form-field-field_0b6af63-2\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-2\">Laparotom\u00eda<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cirug\u00eda abdominal o p\u00e9lvica reciente (menos de 1 a\u00f1o)\" id=\"form-field-field_0b6af63-3\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-3\">Cirug\u00eda abdominal o p\u00e9lvica reciente (menos de 1 a\u00f1o)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Accidentes o lesiones que afecten el sistema digestivo\" id=\"form-field-field_0b6af63-4\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-4\">Accidentes o lesiones que afecten el sistema digestivo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Enfermedades gastrointestinales inflamatorias\" id=\"form-field-field_0b6af63-5\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-5\">Enfermedades gastrointestinales inflamatorias<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ninguna de las anteriores\" id=\"form-field-field_0b6af63-6\" name=\"form_fields[field_0b6af63][]\"> <label for=\"form-field-field_0b6af63-6\">Ninguna de las anteriores<\/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_e00232c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e00232c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTienes o has tenido alguna de estas condiciones m\u00e9dicas relacionadas con el sistema digestivo?\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=\"Gastritis\" id=\"form-field-field_e00232c-0\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-0\">Gastritis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Esofagitis\" id=\"form-field-field_e00232c-1\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-1\">Esofagitis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"\u00dalceras\" id=\"form-field-field_e00232c-2\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-2\">\u00dalceras<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"V\u00e1rices esof\u00e1gicas\" id=\"form-field-field_e00232c-3\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-3\">V\u00e1rices esof\u00e1gicas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"V\u00e1rices g\u00e1stricas\" id=\"form-field-field_e00232c-4\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-4\">V\u00e1rices g\u00e1stricas<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Ninguna de las anteriores\" id=\"form-field-field_e00232c-5\" name=\"form_fields[field_e00232c][]\"> <label for=\"form-field-field_e00232c-5\">Ninguna de las anteriores<\/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_6b7f295 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_6b7f295\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTe comprometes a seguir el esquema de tratamiento m\u00e9dico recomendado dentro del programa?\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=\"Si\" id=\"form-field-field_6b7f295-0\" name=\"form_fields[field_6b7f295]\" required=\"required\"> <label for=\"form-field-field_6b7f295-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6b7f295-1\" name=\"form_fields[field_6b7f295]\" required=\"required\"> <label for=\"form-field-field_6b7f295-1\">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_e9871b2 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-realizas_actividad_fisica 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-realizas_actividad_fisica\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfRealizas actividad f\u00edsica regularmente?\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=\"Si\" id=\"form-field-realizas_actividad_fisica-0\" name=\"form_fields[realizas_actividad_fisica]\" required=\"required\"> <label for=\"form-field-realizas_actividad_fisica-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-realizas_actividad_fisica-1\" name=\"form_fields[realizas_actividad_fisica]\" required=\"required\"> <label for=\"form-field-realizas_actividad_fisica-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-frecuencia_actividad_fisica elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-frecuencia_actividad_fisica\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCon qu\u00e9 frecuencia realizas actividad f\u00edsica?\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=\"Ocasionalmente (1 vez por semana o menos)\" id=\"form-field-frecuencia_actividad_fisica-0\" name=\"form_fields[frecuencia_actividad_fisica]\"> <label for=\"form-field-frecuencia_actividad_fisica-0\">Ocasionalmente (1 vez por semana o menos)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Moderado (2-3 veces por semana)\" id=\"form-field-frecuencia_actividad_fisica-1\" name=\"form_fields[frecuencia_actividad_fisica]\"> <label for=\"form-field-frecuencia_actividad_fisica-1\">Moderado (2-3 veces por semana)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Frecuente (4-5 veces por semana)\" id=\"form-field-frecuencia_actividad_fisica-2\" name=\"form_fields[frecuencia_actividad_fisica]\"> <label for=\"form-field-frecuencia_actividad_fisica-2\">Frecuente (4-5 veces por semana)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Diario\" id=\"form-field-frecuencia_actividad_fisica-3\" name=\"form_fields[frecuencia_actividad_fisica]\"> <label for=\"form-field-frecuencia_actividad_fisica-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-tipo_actividad_fisica elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-tipo_actividad_fisica\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTipo de actividad fisica\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=\"Cardiovascular (correr, caminar, ciclismo, nataci\u00f3n)\" id=\"form-field-tipo_actividad_fisica-0\" name=\"form_fields[tipo_actividad_fisica]\"> <label for=\"form-field-tipo_actividad_fisica-0\">Cardiovascular (correr, caminar, ciclismo, nataci\u00f3n)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Entrenamiento de fuerza (pesas, calistenia, m\u00e1quinas de gimnasio)\" id=\"form-field-tipo_actividad_fisica-1\" name=\"form_fields[tipo_actividad_fisica]\"> <label for=\"form-field-tipo_actividad_fisica-1\">Entrenamiento de fuerza (pesas, calistenia, m\u00e1quinas de gimnasio)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Ejercicio funcional (yoga, pilates, entrenamiento en circuito)\" id=\"form-field-tipo_actividad_fisica-2\" name=\"form_fields[tipo_actividad_fisica]\"> <label for=\"form-field-tipo_actividad_fisica-2\">Ejercicio funcional (yoga, pilates, entrenamiento en circuito)<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Deportes (f\u00fatbol, tenis, baloncesto, etc.)\" id=\"form-field-tipo_actividad_fisica-3\" name=\"form_fields[tipo_actividad_fisica]\"> <label for=\"form-field-tipo_actividad_fisica-3\">Deportes (f\u00fatbol, tenis, baloncesto, etc.)<\/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_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-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=\"Si\" id=\"form-field-cesareas-0\" name=\"form_fields[cesareas]\"> <label for=\"form-field-cesareas-0\">Si<\/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_39475d2 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-has_sido_diagnosticado_trastorno 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-has_sido_diagnosticado_trastorno\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfHas sido diagnosticado con alg\u00fan trastorno alimenticio?\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-has_sido_diagnosticado_trastorno-0\" name=\"form_fields[has_sido_diagnosticado_trastorno]\" required=\"required\"> <label for=\"form-field-has_sido_diagnosticado_trastorno-0\">Si<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-has_sido_diagnosticado_trastorno-1\" name=\"form_fields[has_sido_diagnosticado_trastorno]\" required=\"required\"> <label for=\"form-field-has_sido_diagnosticado_trastorno-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-especifica_diagnostico_trastorno elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-especifica_diagnostico_trastorno\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEspecifica el diagn\u00f3stico o trastorno asociado\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[especifica_diagnostico_trastorno]\" id=\"form-field-especifica_diagnostico_trastorno\" 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-field_99c9c60 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_99c9c60\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1l consideras que es la causa principal de tu sobrepeso?\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_99c9c60]\" id=\"form-field-field_99c9c60\" 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-field_140f311 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_140f311\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1ntas comidas completas realizas al d\u00eda?\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=\"Entre 1-2\" id=\"form-field-field_140f311-0\" name=\"form_fields[field_140f311]\" required=\"required\"> <label for=\"form-field-field_140f311-0\">Entre 1-2<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"3\" id=\"form-field-field_140f311-1\" name=\"form_fields[field_140f311]\" required=\"required\"> <label for=\"form-field-field_140f311-1\">3<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"4 o m\u00e1s\" id=\"form-field-field_140f311-2\" name=\"form_fields[field_140f311]\" required=\"required\"> <label for=\"form-field-field_140f311-2\">4 o m\u00e1s<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Var\u00eda seg\u00fan el d\u00eda\" id=\"form-field-field_140f311-3\" name=\"form_fields[field_140f311]\" required=\"required\"> <label for=\"form-field-field_140f311-3\">Var\u00eda seg\u00fan el d\u00eda<\/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-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-acceptance elementor-field-group elementor-column elementor-field-group-field_a87aeff 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_a87aeff]\" id=\"form-field-field_a87aeff\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_a87aeff\">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_1e7b56e 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_1e7b56e]\" id=\"form-field-field_1e7b56e\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_1e7b56e\">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_2a28c3a 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_2a28c3a]\" id=\"form-field-field_2a28c3a\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_2a28c3a\">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-6c94eb6 elementor-widget elementor-widget-html\" data-id=\"6c94eb6\" 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[has_sido_diagnosticado_trastorno]\"]', conditional: '[name=\"form_fields[especifica_diagnostico_trastorno]\"]' },\r\n        { trigger: '[name=\"form_fields[realizas_actividad_fisica]\"]', conditional: '[name=\"form_fields[frecuencia_actividad_fisica]\"]' },\r\n        { trigger: '[name=\"form_fields[realizas_actividad_fisica]\"]', conditional: '[name=\"form_fields[tipo_actividad_fisica]\"]' }\r\n    ];\r\n\r\n    \/\/ Ocultar todos los campos condicionales y eliminar required 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('display', 'none');\r\n            conditional.removeAttr('required'); \/\/ Elimina el atributo required cuando est\u00e1 oculto\r\n        }\r\n    });\r\n\r\n    \/\/ Funci\u00f3n para manejar la l\u00f3gica condicional y validaci\u00f3n\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        console.log('Valor del campo desencadenante:', value); \/\/ Depuraci\u00f3n\r\n        if (value === 'yeah' || value === 'yes' || value === 's\u00ed' || value === 'si') {\r\n            console.log('Mostrando campo condicional:', conditional.attr('name'));\r\n            fieldGroup.css('display', 'block');\r\n            conditional.attr('required', 'required'); \/\/ A\u00f1ade required cuando se muestra\r\n        } else {\r\n            console.log('Ocultando campo condicional:', conditional.attr('name'));\r\n            fieldGroup.css('display', 'none');\r\n            conditional.removeAttr('required'); \/\/ Elimina required cuando se oculta\r\n        }\r\n    }\r\n\r\n    \/\/ Aplicar l\u00f3gica condicional solo al cambiar\r\n    conditions.forEach(function(pair) {\r\n        var trigger = $(pair.trigger);\r\n        var conditional = $(pair.conditional);\r\n        if (trigger.length && conditional.length) {\r\n            console.log('Campo desencadenante encontrado:', trigger.attr('name'));\r\n            console.log('Campo condicional encontrado:', conditional.attr('name'));\r\n            trigger.on('change', function() {\r\n                toggleConditional($(this), conditional); \/\/ Aplica la l\u00f3gica al cambiar\r\n            });\r\n        } else {\r\n            console.log('Error: No se encontraron los campos - Trigger:', pair.trigger, 'Conditional:', pair.conditional);\r\n        }\r\n    });\r\n});\r\n<\/script>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Schedule your free consultation for your Bariatric Surgery<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-785","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Formulario Cirug\u00eda Bari\u00e1trica - Lefny Plastic Surgery<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/lefnyplasticsurgery.com\/en\/formulario-cirugia-bariatrica\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Formulario Cirug\u00eda Bari\u00e1trica - Lefny Plastic Surgery\" \/>\n<meta property=\"og:description\" content=\"Agenda tu consulta gratuita para tu Cirug\u00eda Bari\u00e1trica\" \/>\n<meta property=\"og:url\" content=\"https:\/\/lefnyplasticsurgery.com\/en\/formulario-cirugia-bariatrica\/\" \/>\n<meta property=\"og:site_name\" content=\"Lefny Plastic Surgery\" \/>\n<meta property=\"article:modified_time\" content=\"2026-03-04T23:32:18+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"9 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/formulario-cirugia-bariatrica\\\/\",\"url\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/formulario-cirugia-bariatrica\\\/\",\"name\":\"Formulario Cirug\u00eda Bari\u00e1trica - Lefny Plastic Surgery\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/#website\"},\"datePublished\":\"2025-02-11T16:01:51+00:00\",\"dateModified\":\"2026-03-04T23:32:18+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/formulario-cirugia-bariatrica\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/lefnyplasticsurgery.com\\\/formulario-cirugia-bariatrica\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/formulario-cirugia-bariatrica\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Portada\",\"item\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Formulario Cirug\u00eda Bari\u00e1trica\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/#website\",\"url\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/\",\"name\":\"Lefny Plastic Surgery\",\"description\":\"Servicio VIP cirug\u00edas est\u00e9ticas en el extranjero\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/lefnyplasticsurgery.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Formulario Cirug\u00eda Bari\u00e1trica - 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