{"id":7676,"date":"2025-03-14T14:30:44","date_gmt":"2025-03-14T14:30:44","guid":{"rendered":"https:\/\/allenorthodontist.com\/formulario-de-historial-medico-del-paciente-nuevo\/"},"modified":"2025-03-26T19:52:16","modified_gmt":"2025-03-26T19:52:16","slug":"formulario-de-historial-medico-del-paciente-nuevo","status":"publish","type":"page","link":"https:\/\/allenorthodontist.com\/es\/formulario-de-historial-medico-del-paciente-nuevo\/","title":{"rendered":"Formulario de historial m\u00e9dico del paciente nuevo"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"7676\" class=\"elementor elementor-7676 elementor-7187\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-particle_enable=\"false\" data-particle-mobile-disabled=\"false\" class=\"elementor-element elementor-element-78cbcc2 e-flex e-con-boxed e-con e-parent\" data-id=\"78cbcc2\" 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 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novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_6\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre del paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_6'>\n                            \n                            <span id='input_1_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_1_6_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_6_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_1_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_6_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Apodo:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Env\u00eda un correo electr\u00f3nico a<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n del paciente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_1_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_7_1' id='input_1_7_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_1_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_7_3' id='input_1_7_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_7_4_container' >\n                                        <select name='input_7.4' id='input_1_7_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Distrito de Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawai' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Luisiana' >Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='Nuevo Hampshire' >Nuevo Hampshire<\/option><option value='Nueva Jersey' >Nueva Jersey<\/option><option value='Nuevo M\u00e9xico' >Nuevo M\u00e9xico<\/option><option value='Nueva York' >Nueva York<\/option><option value='Carolina del Norte' >Carolina del Norte<\/option><option value='Dakota del Norte' >Dakota del Norte<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oreg\u00f3n' >Oreg\u00f3n<\/option><option value='Pensilvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Carolina del Sur' >Carolina del Sur<\/option><option value='Dakota del Sur' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='Virginia Occidental' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Fuerzas Armadas de Am\u00e9rica' >Fuerzas Armadas de Am\u00e9rica<\/option><option value='Fuerzas Armadas Europa' >Fuerzas Armadas Europa<\/option><option value='Fuerzas Armadas del Pac\u00edfico' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for='input_1_7_4' id='input_1_7_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_1_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_7_5' id='input_1_7_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_1_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'>Fecha de nacimiento:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_1_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_8_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_8_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_8' class='gform_hidden' value='https:\/\/allenorthodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_84\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_84'>Tel\u00e9fono m\u00f3vil:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_1_84' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >G\u00e9nero<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_10'>\n\t\t\t<div class='gchoice gchoice_1_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Hombre'  id='choice_1_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_0' id='label_1_10_0' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Mujer'  id='choice_1_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>Mujer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Escuela \/ Nombre del empleador:<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_1_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>Grado \/ Puesto:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_13\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Intereses\/Deportes:<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_1_13' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Responsable principal<\/h3><\/div><fieldset id=\"field_1_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEl Responsable Principal es el mismo que el anterior?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_82'>\n\t\t\t<div class='gchoice gchoice_1_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='S\u00ed'  id='choice_1_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_82_0' id='label_1_82_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_1_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_82_1' id='label_1_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Nombre del responsable principal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>FECHA DE NACIMIENTO:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_1_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_18_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_18_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_18' class='gform_hidden' value='https:\/\/allenorthodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relaci\u00f3n con el paciente:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_15'>\n\t\t\t<div class='gchoice gchoice_1_15_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Madre'  id='choice_1_15_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_0' id='label_1_15_0' class='gform-field-label gform-field-label--type-inline'>Madre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Padre'  id='choice_1_15_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_1' id='label_1_15_1' class='gform-field-label gform-field-label--type-inline'>Padre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Padrastro\/madrastra'  id='choice_1_15_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_2' id='label_1_15_2' class='gform-field-label gform-field-label--type-inline'>Padrastro\/madrastra<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Auto'  id='choice_1_15_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_3' id='label_1_15_3' class='gform-field-label gform-field-label--type-inline'>Auto<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_15_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_15' type='radio' value='Otros'  id='choice_1_15_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_15_4' id='label_1_15_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Si es otro, especif\u00edcalo:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_19\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_19' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_19_1_container' >\n                                        <input type='text' name='input_19.1' id='input_1_19_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_19_1' id='input_1_19_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_19_3_container' >\n                                    <input type='text' name='input_19.3' id='input_1_19_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_3' id='input_1_19_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_19_4_container' >\n                                        <select name='input_19.4' id='input_1_19_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Distrito de Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawai' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Luisiana' >Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='Nuevo Hampshire' >Nuevo Hampshire<\/option><option value='Nueva Jersey' >Nueva Jersey<\/option><option value='Nuevo M\u00e9xico' >Nuevo M\u00e9xico<\/option><option value='Nueva York' >Nueva York<\/option><option value='Carolina del Norte' >Carolina del Norte<\/option><option value='Dakota del Norte' >Dakota del Norte<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oreg\u00f3n' >Oreg\u00f3n<\/option><option value='Pensilvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Carolina del Sur' >Carolina del Sur<\/option><option value='Dakota del Sur' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='Virginia Occidental' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Fuerzas Armadas de Am\u00e9rica' >Fuerzas Armadas de Am\u00e9rica<\/option><option value='Fuerzas Armadas Europa' >Fuerzas Armadas Europa<\/option><option value='Fuerzas Armadas del Pac\u00edfico' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for='input_1_19_4' id='input_1_19_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_19_5_container' >\n                                    <input type='text' name='input_19.5' id='input_1_19_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_19_5' id='input_1_19_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_19.6' id='input_1_19_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Empleador\/Direcci\u00f3n:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>C\u00e9lula de la Parte Primaria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_21' id='input_1_21' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>N\u00famero principal de la Seguridad Social:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_1_22' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Direcci\u00f3n de correo electr\u00f3nico principal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_23' id='input_1_23' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Responsable secundario<\/h3><\/div><fieldset id=\"field_1_83\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfHay otra Parte Responsable?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_83'>\n\t\t\t<div class='gchoice gchoice_1_83_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='S\u00ed'  id='choice_1_83_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_83_0' id='label_1_83_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_83_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_83' type='radio' value='No'  id='choice_1_83_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_83_1' id='label_1_83_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_27'>Nombre del responsable secundario:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>FECHA DE NACIMIENTO:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_1_28' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_28_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_28_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_28' class='gform_hidden' value='https:\/\/allenorthodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_1_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relaci\u00f3n con el paciente:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_25'>\n\t\t\t<div class='gchoice gchoice_1_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Madre'  id='choice_1_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_0' id='label_1_25_0' class='gform-field-label gform-field-label--type-inline'>Madre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Padre'  id='choice_1_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_1' id='label_1_25_1' class='gform-field-label gform-field-label--type-inline'>Padre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Padrastro\/madrastra'  id='choice_1_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_2' id='label_1_25_2' class='gform-field-label gform-field-label--type-inline'>Padrastro\/madrastra<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Auto'  id='choice_1_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_3' id='label_1_25_3' class='gform-field-label gform-field-label--type-inline'>Auto<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_25_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Otros'  id='choice_1_25_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_25_4' id='label_1_25_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_26'>Si es otro, especif\u00edcalo:<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_29\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_29' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_29_1_container' >\n                                        <input type='text' name='input_29.1' id='input_1_29_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_29_1' id='input_1_29_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_29_3_container' >\n                                    <input type='text' name='input_29.3' id='input_1_29_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_29_3' id='input_1_29_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_29_4_container' >\n                                        <select name='input_29.4' id='input_1_29_4'     aria-required='false'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='Distrito de Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawai' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Luisiana' >Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='Nuevo Hampshire' >Nuevo Hampshire<\/option><option value='Nueva Jersey' >Nueva Jersey<\/option><option value='Nuevo M\u00e9xico' >Nuevo M\u00e9xico<\/option><option value='Nueva York' >Nueva York<\/option><option value='Carolina del Norte' >Carolina del Norte<\/option><option value='Dakota del Norte' >Dakota del Norte<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oreg\u00f3n' >Oreg\u00f3n<\/option><option value='Pensilvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='Carolina del Sur' >Carolina del Sur<\/option><option value='Dakota del Sur' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='Virginia Occidental' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Fuerzas Armadas de Am\u00e9rica' >Fuerzas Armadas de Am\u00e9rica<\/option><option value='Fuerzas Armadas Europa' >Fuerzas Armadas Europa<\/option><option value='Fuerzas Armadas del Pac\u00edfico' >Fuerzas Armadas del Pac\u00edfico<\/option><\/select>\n                                        <label for='input_1_29_4' id='input_1_29_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_29_5_container' >\n                                    <input type='text' name='input_29.5' id='input_1_29_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_29_5' id='input_1_29_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_29.6' id='input_1_29_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Empleador\/Direcci\u00f3n:<\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_31'>C\u00e9lula de la Parte Secundaria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_1_31' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_32'>N\u00famero de la Seguridad Social:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_32' id='input_1_32' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_33'>Direcci\u00f3n de correo electr\u00f3nico de la parte secundaria:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_1_33' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfC\u00f3mo nos conociste?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_34'>\n\t\t\t<div class='gchoice gchoice_1_34_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Dentista'  id='choice_1_34_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_0' id='label_1_34_0' class='gform-field-label gform-field-label--type-inline'>Dentista<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Paciente'  id='choice_1_34_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Paciente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Relativa'  id='choice_1_34_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Relativa<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Conocido'  id='choice_1_34_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_3' id='label_1_34_3' class='gform-field-label gform-field-label--type-inline'>Conocido<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_34_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_34' type='radio' value='Otros'  id='choice_1_34_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_34_4' id='label_1_34_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_35'>Si es otro, especif\u00edcalo:<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_36'>Dentista actual:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_37'>Motivo de la consulta:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Obligatorio)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_37' id='input_1_37' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_1_38\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Comprueba si el paciente tiene antecedentes de lo siguiente:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_38'><div class='gchoice gchoice_1_38_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.1' type='checkbox'  value='TDA\/TDAH'  id='choice_1_38_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_1' id='label_1_38_1' class='gform-field-label gform-field-label--type-inline'>TDA\/TDAH<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.2' type='checkbox'  value='VIH\/SIDA'  id='choice_1_38_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_2' id='label_1_38_2' class='gform-field-label gform-field-label--type-inline'>VIH\/SIDA<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.3' type='checkbox'  value='Alergias'  id='choice_1_38_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_3' id='label_1_38_3' class='gform-field-label gform-field-label--type-inline'>Alergias<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.4' type='checkbox'  value='Anemia'  id='choice_1_38_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_4' id='label_1_38_4' class='gform-field-label gform-field-label--type-inline'>Anemia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.5' type='checkbox'  value='Artritis, Reumatismo'  id='choice_1_38_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_5' id='label_1_38_5' class='gform-field-label gform-field-label--type-inline'>Artritis, Reumatismo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.6' type='checkbox'  value='Autismo'  id='choice_1_38_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_6' id='label_1_38_6' class='gform-field-label gform-field-label--type-inline'>Autismo<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.7' type='checkbox'  value='Asma'  id='choice_1_38_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_7' id='label_1_38_7' class='gform-field-label gform-field-label--type-inline'>Asma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.8' type='checkbox'  value='Autoinmune'  id='choice_1_38_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_8' id='label_1_38_8' class='gform-field-label gform-field-label--type-inline'>Autoinmune<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.9' type='checkbox'  value='Trastornos \u00f3seos'  id='choice_1_38_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_9' id='label_1_38_9' class='gform-field-label gform-field-label--type-inline'>Trastornos \u00f3seos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.11' type='checkbox'  value='Bulimia'  id='choice_1_38_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_11' id='label_1_38_11' class='gform-field-label gform-field-label--type-inline'>Bulimia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.12' type='checkbox'  value='C\u00e1ncer'  id='choice_1_38_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_12' id='label_1_38_12' class='gform-field-label gform-field-label--type-inline'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.13' type='checkbox'  value='Par\u00e1lisis cerebral'  id='choice_1_38_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_13' id='label_1_38_13' class='gform-field-label gform-field-label--type-inline'>Par\u00e1lisis cerebral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.14' type='checkbox'  value='Dolores tor\u00e1cicos'  id='choice_1_38_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_14' id='label_1_38_14' class='gform-field-label gform-field-label--type-inline'>Dolores tor\u00e1cicos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.15' type='checkbox'  value='Dolor de cuello cr\u00f3nico'  id='choice_1_38_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_15' id='label_1_38_15' class='gform-field-label gform-field-label--type-inline'>Dolor de cuello cr\u00f3nico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.16' type='checkbox'  value='Chasquido de mand\u00edbula'  id='choice_1_38_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_16' id='label_1_38_16' class='gform-field-label gform-field-label--type-inline'>Chasquido de mand\u00edbula<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.17' type='checkbox'  value='Herpes Labial\/Herpes'  id='choice_1_38_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_17' id='label_1_38_17' class='gform-field-label gform-field-label--type-inline'>Herpes Labial\/Herpes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.18' type='checkbox'  value='Diabetes'  id='choice_1_38_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_18' id='label_1_38_18' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.19' type='checkbox'  value='Uso de pastillas para adelgazar'  id='choice_1_38_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_19' id='label_1_38_19' class='gform-field-label gform-field-label--type-inline'>Uso de pastillas para adelgazar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.21' type='checkbox'  value='S\u00edndrome de Down'  id='choice_1_38_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_21' id='label_1_38_21' class='gform-field-label gform-field-label--type-inline'>S\u00edndrome de Down<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.22' type='checkbox'  value='Alergias a medicamentos'  id='choice_1_38_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_22' id='label_1_38_22' class='gform-field-label gform-field-label--type-inline'>Alergias a medicamentos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.23' type='checkbox'  value='Problemas endocrinos'  id='choice_1_38_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_23' id='label_1_38_23' class='gform-field-label gform-field-label--type-inline'>Problemas endocrinos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_24'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.24' type='checkbox'  value='Trastornos emocionales'  id='choice_1_38_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_24' id='label_1_38_24' class='gform-field-label gform-field-label--type-inline'>Trastornos emocionales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_25'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.25' type='checkbox'  value='Epilepsia'  id='choice_1_38_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_25' id='label_1_38_25' class='gform-field-label gform-field-label--type-inline'>Epilepsia<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_26'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.26' type='checkbox'  value='Desmayos, mareos'  id='choice_1_38_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_26' id='label_1_38_26' class='gform-field-label gform-field-label--type-inline'>Desmayos, mareos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_27'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.27' type='checkbox'  value='Glaucoma'  id='choice_1_38_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_27' id='label_1_38_27' class='gform-field-label gform-field-label--type-inline'>Glaucoma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_28'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.28' type='checkbox'  value='Dolores de cabeza'  id='choice_1_38_28'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_28' id='label_1_38_28' class='gform-field-label gform-field-label--type-inline'>Dolores de cabeza<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_29'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.29' type='checkbox'  value='Cardiopat\u00eda'  id='choice_1_38_29'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_29' id='label_1_38_29' class='gform-field-label gform-field-label--type-inline'>Cardiopat\u00eda<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_31'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.31' type='checkbox'  value='Hepatitis'  id='choice_1_38_31'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_31' id='label_1_38_31' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_32'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.32' type='checkbox'  value='Hipertensi\u00f3n arterial'  id='choice_1_38_32'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_32' id='label_1_38_32' class='gform-field-label gform-field-label--type-inline'>Hipertensi\u00f3n arterial<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_33'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.33' type='checkbox'  value='Problemas inmunitarios'  id='choice_1_38_33'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_33' id='label_1_38_33' class='gform-field-label gform-field-label--type-inline'>Problemas inmunitarios<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_34'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.34' type='checkbox'  value='Problemas renales'  id='choice_1_38_34'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_34' id='label_1_38_34' class='gform-field-label gform-field-label--type-inline'>Problemas renales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_35'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.35' type='checkbox'  value='Alergia al l\u00e1tex'  id='choice_1_38_35'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_35' id='label_1_38_35' class='gform-field-label gform-field-label--type-inline'>Alergia al l\u00e1tex<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_36'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.36' type='checkbox'  value='Tensi\u00f3n arterial baja'  id='choice_1_38_36'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_36' id='label_1_38_36' class='gform-field-label gform-field-label--type-inline'>Tensi\u00f3n arterial baja<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_37'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.37' type='checkbox'  value='Respiraci\u00f3n bucal'  id='choice_1_38_37'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_37' id='label_1_38_37' class='gform-field-label gform-field-label--type-inline'>Respiraci\u00f3n bucal<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_38'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.38' type='checkbox'  value='Trastornos musculares'  id='choice_1_38_38'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_38' id='label_1_38_38' class='gform-field-label gform-field-label--type-inline'>Trastornos musculares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_39'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.39' type='checkbox'  value='Trastornos nerviosos'  id='choice_1_38_39'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_39' id='label_1_38_39' class='gform-field-label gform-field-label--type-inline'>Trastornos nerviosos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_41'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.41' type='checkbox'  value='Trasplante de \u00f3rganos'  id='choice_1_38_41'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_41' id='label_1_38_41' class='gform-field-label gform-field-label--type-inline'>Trasplante de \u00f3rganos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_42'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.42' type='checkbox'  value='Masticaci\u00f3n dolorosa'  id='choice_1_38_42'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_42' id='label_1_38_42' class='gform-field-label gform-field-label--type-inline'>Masticaci\u00f3n dolorosa<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_43'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.43' type='checkbox'  value='Problemas periodontales'  id='choice_1_38_43'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_43' id='label_1_38_43' class='gform-field-label gform-field-label--type-inline'>Problemas periodontales<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_44'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.44' type='checkbox'  value='Neumon\u00eda'  id='choice_1_38_44'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_44' id='label_1_38_44' class='gform-field-label gform-field-label--type-inline'>Neumon\u00eda<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_45'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.45' type='checkbox'  value='Embarazada'  id='choice_1_38_45'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_45' id='label_1_38_45' class='gform-field-label gform-field-label--type-inline'>Embarazada<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_46'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.46' type='checkbox'  value='Hemorragia prolongada'  id='choice_1_38_46'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_46' id='label_1_38_46' class='gform-field-label gform-field-label--type-inline'>Hemorragia prolongada<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_47'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.47' type='checkbox'  value='Fiebre reum\u00e1tica'  id='choice_1_38_47'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_47' id='label_1_38_47' class='gform-field-label gform-field-label--type-inline'>Fiebre reum\u00e1tica<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_48'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.48' type='checkbox'  value='Escoliosis'  id='choice_1_38_48'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_48' id='label_1_38_48' class='gform-field-label gform-field-label--type-inline'>Escoliosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_49'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.49' type='checkbox'  value='Convulsiones'  id='choice_1_38_49'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_49' id='label_1_38_49' class='gform-field-label gform-field-label--type-inline'>Convulsiones<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_51'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.51' type='checkbox'  value='Sicca'  id='choice_1_38_51'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_51' id='label_1_38_51' class='gform-field-label gform-field-label--type-inline'>Sicca<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_52'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.52' type='checkbox'  value='Fumar\/Tabaco'  id='choice_1_38_52'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_52' id='label_1_38_52' class='gform-field-label gform-field-label--type-inline'>Fumar\/Tabaco<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_53'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.53' type='checkbox'  value='Problemas de habla'  id='choice_1_38_53'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_53' id='label_1_38_53' class='gform-field-label gform-field-label--type-inline'>Problemas de habla<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_54'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.54' type='checkbox'  value='Problemas de ATM'  id='choice_1_38_54'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_54' id='label_1_38_54' class='gform-field-label gform-field-label--type-inline'>Problemas de ATM<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_55'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.55' type='checkbox'  value='Rechinar los dientes'  id='choice_1_38_55'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_55' id='label_1_38_55' class='gform-field-label gform-field-label--type-inline'>Rechinar los dientes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_56'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.56' type='checkbox'  value='Tuberculosis'  id='choice_1_38_56'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_56' id='label_1_38_56' class='gform-field-label gform-field-label--type-inline'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_57'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.57' type='checkbox'  value='Enfermedades Ven\u00e9reas (ETS)'  id='choice_1_38_57'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_57' id='label_1_38_57' class='gform-field-label gform-field-label--type-inline'>Enfermedades Ven\u00e9reas (ETS)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_58'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.58' type='checkbox'  value='Sinusitis'  id='choice_1_38_58'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_58' id='label_1_38_58' class='gform-field-label gform-field-label--type-inline'>Sinusitis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_59'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.59' type='checkbox'  value='Pr\u00f3tesis articulares'  id='choice_1_38_59'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_59' id='label_1_38_59' class='gform-field-label gform-field-label--type-inline'>Pr\u00f3tesis articulares<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_38_61'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_38.61' type='checkbox'  value='Medicamentos \u00f3seos'  id='choice_1_38_61'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_38_61' id='label_1_38_61' class='gform-field-label gform-field-label--type-inline'>Medicamentos \u00f3seos<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>\u00bfAlguna enfermedad, problema o alergia no mencionados anteriormente?<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_40\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>\u00bfMedicamentos actuales?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_40' id='input_1_40' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Mujeres: \u00bfHas empezado a menstruar?<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_42'>\u00bfA qu\u00e9 edad?<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_1_42' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>\u00bfTe han extra\u00eddo las muelas del juicio?<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_44'>\u00bfAlguna lesi\u00f3n en la cara, boca o dientes?<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_45'>\u00bfEl paciente respira normalmente por la boca mientras est\u00e1 despierto o dormido?<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_1_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'>\u00bfSangran las enc\u00edas al cepillarse o utilizar el hilo dental?<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_47\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_47'>\u00bfCu\u00e1ndo fue tu \u00faltima limpieza y revisi\u00f3n dental?<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_1_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>\u00bfAlg\u00fan trabajo dental pendiente?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_1_48' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_49'>\u00bfTe has sometido anteriormente a un tratamiento de ortodoncia?<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>\u00bfFaltan o sobran dientes?<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_51'>\u00bfTe han extirpado las am\u00edgdalas y las adenoides?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_1_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_52'>\u00bfAlg\u00fan h\u00e1bito oral como chuparse el dedo o morderse las u\u00f1as?<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_1_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>Nombres y edades de hermanos y hermanas:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_1_53' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Informaci\u00f3n sobre el seguro<\/h3>\n<p><strong>(Rell\u00e9nalo completamente para que podamos tramitar correctamente tu seguro)<\/strong><\/p><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>Seguro principal de ortodoncia:<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_56'>Tel\u00e9fono del Seguro:<\/label><div class='ginput_container ginput_container_phone'><input name='input_56' id='input_1_56' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_58\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_58'>N\u00famero de identificaci\u00f3n de socio:<\/label><div class='ginput_container ginput_container_number'><input name='input_58' id='input_1_58' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_59'>N\u00famero de grupo:<\/label><div class='ginput_container ginput_container_number'><input name='input_59' id='input_1_59' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>Nombre del titular de la p\u00f3liza:<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_61\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relaci\u00f3n:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_61'>\n\t\t\t<div class='gchoice gchoice_1_61_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Madre'  id='choice_1_61_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_0' id='label_1_61_0' class='gform-field-label gform-field-label--type-inline'>Madre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Padre'  id='choice_1_61_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>Padre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Padrastro\/madrastra'  id='choice_1_61_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_2' id='label_1_61_2' class='gform-field-label gform-field-label--type-inline'>Padrastro\/madrastra<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Auto'  id='choice_1_61_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_3' id='label_1_61_3' class='gform-field-label gform-field-label--type-inline'>Auto<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_61_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_61' type='radio' value='Otros'  id='choice_1_61_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_61_4' id='label_1_61_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_62\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>Si es otro, especif\u00edcalo:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_63'>Fecha de nacimiento del titular de la p\u00f3liza:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_1_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_63_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_63_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_63' class='gform_hidden' value='https:\/\/allenorthodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_65'>Seguro secundario de ortodoncia:<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_1_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_66'>Tel\u00e9fono del Seguro:<\/label><div class='ginput_container ginput_container_phone'><input name='input_66' id='input_1_66' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>N\u00famero de identificaci\u00f3n de socio:<\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_1_67' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_68'>N\u00famero de grupo:<\/label><div class='ginput_container ginput_container_number'><input name='input_68' id='input_1_68' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_69'>Nombre del titular de la p\u00f3liza:<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Relaci\u00f3n<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_70'>\n\t\t\t<div class='gchoice gchoice_1_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Madre'  id='choice_1_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_0' id='label_1_70_0' class='gform-field-label gform-field-label--type-inline'>Madre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Padre'  id='choice_1_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_1' id='label_1_70_1' class='gform-field-label gform-field-label--type-inline'>Padre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_70_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Padrastro\/madrastra'  id='choice_1_70_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_2' id='label_1_70_2' class='gform-field-label gform-field-label--type-inline'>Padrastro\/madrastra<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_70_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Auto'  id='choice_1_70_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_3' id='label_1_70_3' class='gform-field-label gform-field-label--type-inline'>Auto<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_70_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Otros'  id='choice_1_70_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_70_4' id='label_1_70_4' class='gform-field-label gform-field-label--type-inline'>Otros<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_71'>Si es otro, especif\u00edcalo:<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_1_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_72'>Fecha de nacimiento del titular de la p\u00f3liza:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_72' id='input_1_72' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_1_72_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_72_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_72' class='gform_hidden' value='https:\/\/allenorthodontist.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_78\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_78'>Firma<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_1_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_74'>Relaci\u00f3n con el paciente:<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_1_74' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el 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Aprende m\\u00e1s sobre la l\\u00f3gica condicional en botones en nuestra <a href=\\\"https:\\\/\\\/docs.gravityforms.com\\\/field-accessibility-warning\\\/\\\" target=\\\"_blank\\\" rel=\\\"noopener\\\">documentaci\\u00f3n<span class=\\\"screen-reader-text\\\">(se abre en una pesta\\u00f1a nueva)<\\\/span>&nbsp;<span class=\\\"gform-icon gform-icon--external-link\\\" aria-hidden=\\\"true\\\"><\\\/span><\\\/a>.\",\"page\":\"P\\u00e1gina\",\"next_button\":\"Bot\\u00f3n siguiente\",\"button\":\"Bot\\u00f3n de enviar\",\"all\":\"Todo\",\"any\":\"Cualquiera\",\"ofTheFollowingMatch\":\"coincide:\",\"is\":\"es\",\"isNot\":\"no est\\u00e1\",\"greaterThan\":\"mayor que\",\"lessThan\":\"menor que\",\"contains\":\"contiene\",\"startsWith\":\"comienza por\",\"endsWith\":\"termina por\",\"emptyChoice\":\"Vac\\u00edo (sin opciones seleccionadas)\",\"alertLegacyMode\":\"Este formulario tiene habilitado un marcado obsoleto y no es compatible con el cambio de tama\\u00f1o de campo dentro del editor. Por favor, desactiva el marcado obsoleto en los ajustes del formulario para activar el cambio de tama\\u00f1o en vivo.\",\"thisConfirmation\":\"Usar esta confirmaci\\u00f3n si\",\"thisNotification\":\"Enviar esta notificaci\\u00f3n si\",\"confirmationSave\":\"Guardar\",\"confirmationSaving\":\"Guardando...\",\"confirmationAreYouSure\":\"\\u00bfEst\\u00e1s seguro de que deseas cancelar estos cambios?\",\"confirmationIssueSaving\":\"Hubo un problema al guardar esta confirmaci\\u00f3n.\",\"confirmationConfirmDelete\":\"\\u00bfSeguro que quieres borrar esta confirmaci\\u00f3n?\",\"confirmationIssueDeleting\":\"Hubo un problema al borrar esta confirmaci\\u00f3n.\",\"confirmationConfirmDiscard\":\"Hay cambios sin guardar en la confirmaci\\u00f3n actual. \\u00bfTe gustar\\u00eda descartar estos cambios?\",\"confirmationDefaultName\":\"Confirmaci\\u00f3n sin t\\u00edtulo\",\"confirmationDefaultMessage\":\"\\u00a1Gracias por contactar con nosotros! Nos pondremos en contacto contigo muy pronto.\",\"confirmationInvalidPageSelection\":\"Selecciona una p\\u00e1gina.\",\"confirmationInvalidRedirect\":\"Introduce una URL.\",\"confirmationInvalidName\":\"Introduce un nombre de confirmaci\\u00f3n.\",\"confirmationDeleteField\":\"Al borrar este campo tambi\\u00e9n se borrar\\u00e1n todos los datos de entrada asociados a \\u00e9l. \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"confirmationDeleteDisplayField\":\"Est\\u00e1s a punto de borrar este campo. \\u00abCancelar\\u00bb para parar. \\u00abAceptar\\u00bb para borrar\",\"confirmationDeleteDisplayFieldTitle\":\"Advertencia\",\"conditionalLogicDependency\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de este campo. Borrar este campo desactivar\\u00e1 esas reglas de l\\u00f3gica condicional y tambi\\u00e9n todos los datos asociados con el campo en las entradas. 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyChoice\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de esta opci\\u00f3n \\u00bfest\\u00e1s seguro de que quieres borrarla?. 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyChoiceEdit\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de esta opci\\u00f3n. \\u00bfEst\\u00e1s seguro de editar esta opci\\u00f3n? 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicDependencyAdminOnly\":\"Este formulario contiene l\\u00f3gica condicional de tipo {type} dependiente de este campo. \\u00bfEst\\u00e1s seguro de que quieres marcar este campo como Administrativo? 'OK' para borrar, 'Cancelar' para abortar.\",\"conditionalLogicRichTextEditorWarning\":\"Este formulario contiene l\\u00f3gica condicional que depende de este campo. No seguir\\u00e1 funcionando si est\\u00e1 activado el editor de texto enriquecido.  \\u00bfQuieres activar el editor de texto enriquecido? \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para continuar.\",\"conditionalLogicTypeButton\":\"bot\\u00f3n\",\"conditionalLogicTypeConfirmation\":\"confirmaci\\u00f3n\",\"conditionalLogicTypeNotification\":\"aviso\",\"conditionalLogicTypeNoficationRouting\":\"enrutamiento de avisos\",\"conditionalLogicTypeField\":\"campo\",\"conditionalLogicTypeFeed\":\"feed\",\"conditionalLogicWarningTitle\":\"Advertencia de l\\u00f3gica condicional\",\"mergeTagsText\":\"Insertar etiquetas de fusi\\u00f3n\",\"baseUrl\":\"https:\\\/\\\/allenorthodontist.com\\\/wp-content\\\/plugins\\\/gravityforms\",\"gf_currency_config\":{\"name\":\"D\\u00f3lar Americano\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"},\"otherChoiceValue\":\"Otro\",\"isFormTrash\":false,\"currentlyAddingField\":false,\"visibilityOptions\":[{\"label\":\"Visible\",\"value\":\"visible\",\"description\":\"Opci\\u00f3n predeterminada. El campo ser\\u00e1 visible cuando se vea el formulario.\"},{\"label\":\"Oculto\",\"value\":\"hidden\",\"description\":\"El campo est\\u00e1 oculto cuando se ve el formulario. \\u00datil cuando necesitas la funcionalidad de este campo pero no quieres que el usurario pueda verlo.\"},{\"label\":\"Administrativo\",\"value\":\"administrative\",\"description\":\"Este campo s\\u00f3lo es visible al administrar entradas enviadas. El campo no es visible o funcional cuando se ve el formulario.\"}],\"addFieldFilter\":\"A\\u00f1adir una condici\\u00f3n\",\"removeFieldFilter\":\"Eliminar una condici\\u00f3n\",\"filterAndAny\":\"{0} de los siguientes coinciden:\",\"customChoices\":\"Opciones personalizadas\",\"predefinedChoices\":\"Opciones predefinidas\",\"fieldLabelAriaLabel\":\"{field_label} - {field_type}, saltar a los ajustes de este campo\",\"fieldCanBeAddedTitle\":\"L\\u00edmite de campo\",\"fieldCanBeAddedCaptcha\":\"Un formulario s\\u00f3lo puede contener un campo CAPTCHA.\",\"fieldCanBeAddedShipping\":\"Un formulario s\\u00f3lo puede contener un campo de tipo de env\\u00edo.\",\"fieldCanBeAddedPostContent\":\"Un formulario s\\u00f3lo puede contener un campo de cuerpo del mensaje.\",\"fieldCanBeAddedPostTitle\":\"Un formulario s\\u00f3lo puede contener un campo de t\\u00edtulo de la entrada.\",\"fieldCanBeAddedPostExcerpt\":\"Un formulario s\\u00f3lo puede contener un campo de extracto de entrada.\",\"fieldCanBeAddedCreditCard\":\"Un formulario s\\u00f3lo puede contener un campo de tarjeta de cr\\u00e9dito.\",\"fieldCanBeAddedProductTitle\":\"Falta el campo de producto\",\"fieldCanBeAddedProduct\":\"Debes a\\u00f1adir un campo de producto primero.\",\"legacyMarkupTitle\":\"Marcado no compatible\",\"fieldCanBeAddedMultipleChoice\":\"No puedes a\\u00f1adir un campo de opci\\u00f3n m\\u00faltiple a un formulario que utiliza marcado heredado. Edita la configuraci\\u00f3n del formulario y desactiva el marcado heredado.\",\"fieldCanBeAddedImageChoice\":\"No puedes a\\u00f1adir un campo de elecci\\u00f3n de imagen a un formulario que utiliza marcado heredado. Edita la configuraci\\u00f3n del formulario y desactiva el marcado heredado.\",\"FieldAjaxonErrorTitle\":\"Error\",\"StartAddFieldAjaxonError\":\"Error de Ajax al a\\u00f1adir un campo. Por favor, actualiza la p\\u00e1gina e int\\u00e9ntalo de nuevo.\",\"StartChangeInputTypeAjaxonError\":\"Error deAjax al cambiar el tipo de entrada. Por favor, actualiza la p\\u00e1gina e int\\u00e9ntalo de nuevo.\",\"MissingNameCustomChoicesTitle\":\"Falta el nombre\",\"MissingNameCustomChoices\":\"Por favor, dale un nombre a esta elecci\\u00f3n personalizada.\",\"DuplicateNameCustomChoicesTitle\":\"Duplicar t\\u00edtulo\",\"DuplicateNameCustomChoices\":\"Esta elecci\\u00f3n personalizada ya est\\u00e1 en uso. Por favor selecciona otro nombre.\",\"DuplicateTitleMessageTitle\":\"Duplicar t\\u00edtulo\",\"DuplicateTitleMessage\":\"El t\\u00edtulo de formulario que has introducido ya est\\u00e1 en uso. Por favor introduce un t\\u00edtulo de formulario \\u00fanico.\",\"ValidateFormMissingFormTitleTitle\":\"Falta el t\\u00edtulo del formulario\",\"ValidateFormMissingFormTitle\":\"Introduce un t\\u00edtulo para este formulario. Cuando a\\u00f1adas un formulario a una entrada o p\\u00e1gina, tendr\\u00e1s la opci\\u00f3n de ocultar el t\\u00edtulo.\",\"ValidateFormEmptyPageTitle\":\"Pagina vacia\",\"ValidateFormEmptyPage\":\"Este formulario tiene actualmente una o m\\u00e1s p\\u00e1ginas sin ning\\u00fan campo. Las p\\u00e1ginas en blanco son el resultado de los saltos de p\\u00e1gina que est\\u00e1n colocados como primer o \\u00faltimo campo del formulario o justo uno detr\\u00e1s de otro. Ajusta los saltos de p\\u00e1gina.\",\"ValidateFormMissingProductLabelTitle\":\"Falta la etiqueta del producto\",\"ValidateFormMissingProductLabel\":\"Este formulario tiene un campo de producto con una etiqueta en blanco. Por favor, introduce una etiqueta para cada campo de producto.\",\"ValidateFormMissingProductFieldTitle\":\"Falta el campo de producto\",\"ValidateFormMissingProductField\":\"Este formulario tiene un campo de opci\\u00f3n sin un campo de producto. Debes a\\u00f1adir un campo de producto a tu formulario.\",\"FormulaIsValidTitle\":\"Correcto\",\"FormulaIsValid\":\"La f\\u00f3rmula parece ser v\\u00e1lida.\",\"FormulaIsInvalid\":\"Parece que hay un problema con la f\\u00f3rmula.\",\"DeleteFormTitle\":\"Confirmar\",\"DeleteForm\":\"Est\\u00e1s a punto de mover este formulario a la papelera. \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"DeleteCustomChoice\":\"\\u00bfBorrar esta lista de opciones personalizada? \\u00abCancelar\\u00bb para abortar. \\u00abAceptar\\u00bb para borrar.\",\"FieldAdded\":\"&nbsp;campo a\\u00f1adido al formulario\",\"nameFieldDefaultPrefixes\":[{\"text\":\"Dr.\",\"value\":\"Dr.\"},{\"text\":\"Prof.\",\"value\":\"Prof.\"},{\"text\":\"Rev.\",\"value\":\"Rev.\"},{\"text\":\"Sr.\",\"value\":\"Sr.\"},{\"text\":\"Sra.\",\"value\":\"Sra.\"},{\"text\":\"Srta.\",\"value\":\"Srta.\"}]};\t\t\t<\/script>\n            \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>Patient Information Name(Required) First Last Nickname:Email Patient Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birth Date: MM slash DD slash YYYY Age: Gender Male Female School \/ Employer&#039;s Name:Grade \/ Position:Interest\/Sports: Primary Responsible [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":24,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"class_list":["post-7676","page","type-page","status-publish"],"_links":{"self":[{"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/pages\/7676","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/comments?post=7676"}],"version-history":[{"count":4,"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/pages\/7676\/revisions"}],"predecessor-version":[{"id":7936,"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/pages\/7676\/revisions\/7936"}],"wp:attachment":[{"href":"https:\/\/allenorthodontist.com\/es\/wp-json\/wp\/v2\/media?parent=7676"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}