{"id":2044,"date":"2024-06-26T23:36:09","date_gmt":"2024-06-26T23:36:09","guid":{"rendered":"https:\/\/prodentalut.com\/?page_id=2044"},"modified":"2026-03-27T07:26:42","modified_gmt":"2026-03-27T13:26:42","slug":"npform","status":"publish","type":"page","link":"https:\/\/prodentalut.com\/es\/npform\/","title":{"rendered":"Formulario de Nuevo Paciente"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"2044\" class=\"elementor elementor-2044\" data-elementor-post-type=\"page\">\n\t\t\t\t<div data-dce-background-overlay-color=\"#2C5D83\" data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-15T140525.866.jpg\" class=\"elementor-element elementor-element-8d7ab20 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"8d7ab20\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:100}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-448e619 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"448e619\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:50}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tFORMULARIO DIGITAL\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e4a0dc5 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"e4a0dc5\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Ahorra Tiempo Completando El Formulario de Nuevo Paciente En L\u00ednea<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-c39c70c elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"c39c70c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tSi eres un paciente nuevo, por favor completa el formulario a continuaci\u00f3n. Nuestra oficina tendr\u00e1 toda la informaci\u00f3n cuando vengas a tu cl\u00ednica asignada.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-88ad559 e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"88ad559\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-7fdbb80 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"7fdbb80\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Bienvenido a Professional Dental<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-36f1a14 elementor-widget elementor-widget-heading\" data-id=\"36f1a14\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Formulario de Nuevo Paciente<\/h1>\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<div class=\"elementor-element elementor-element-0c9e150 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"0c9e150\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-6a9da7d e-con-full e-flex e-con e-child\" data-id=\"6a9da7d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-inline-align=\"{&quot;fields&quot;:[{&quot;custom_id&quot;:&quot;responpayment&quot;,&quot;field_id&quot;:&quot;1ec35a4&quot;}]}\" data-dce-field-description=\"{&quot;fields&quot;:[{&quot;custom_id&quot;:&quot;pdoffice&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;You can change it later&quot;,&quot;description_text&quot;:&quot;You can change it later&quot;},{&quot;custom_id&quot;:&quot;medicalundertreatexplain&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalhospitalizedexplain&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;field_078ca55&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalbisphosphaonateshowlong&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;},{&quot;custom_id&quot;:&quot;medicalttobaccohowlong&quot;,&quot;position&quot;:&quot;elementor-field&quot;,&quot;description&quot;:&quot;The more details, the better&quot;,&quot;description_text&quot;:&quot;The more details, the better&quot;}]}\" class=\"elementor-element elementor-element-8cd5c9e elementor-button-align-end elementor-invisible elementor-widget elementor-widget-form\" data-id=\"8cd5c9e\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;NEXT&quot;,&quot;step_previous_label&quot;:&quot;PREVIOUS&quot;,&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:10,&quot;sizes&quot;:[]},&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150,&quot;button_width&quot;:&quot;100&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"dce-conditions-js-error-notice elementor-message elementor-message-danger\" style=\"display: none;\">A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.<\/div>\t\t\t<script>\n\t\t\tsetTimeout(function() {\n\t\t\t\tlet el = document.querySelector(\".dce-conditions-js-error-notice\");\n\t\t\t\tif (el)\n\t\t\t\t\tel.style.display = \"block\";\n\t\t\t}, 6000);\n\t\t\t<\/script>\t\t<form class=\"elementor-form\" method=\"post\" name=\"NP Form\" aria-label=\"Formulario NP\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2044\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"8cd5c9e\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"\" \/>\n\n\t\t\t\n\t\t\t<div data-autocomplete-fields=\"[{&quot;id&quot;:&quot;personalpatientmailinadd&quot;,&quot;country&quot;:[&quot;US&quot;]},{&quot;id&quot;:&quot;responmail&quot;,&quot;country&quot;:[&quot;US&quot;]},{&quot;id&quot;:&quot;insuranceaddress&quot;,&quot;country&quot;:[&quot;US&quot;]}]\" data-field-conditions=\"[{&quot;id&quot;:&quot;fullnamefamilyfriend&quot;,&quot;condition&quot;:&quot;(personalhowhear == 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class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6ec801b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column 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value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-fullname elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fullname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[fullname]\" id=\"form-field-fullname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre de pila...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-lastname elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-lastname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tApellido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[lastname]\" id=\"form-field-lastname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Apellido...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-prefercalled elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-prefercalled\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre Preferido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[prefercalled]\" id=\"form-field-prefercalled\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre preferido...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-birthdate elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-birthdate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[birthdate]\" id=\"form-field-birthdate\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha de nacimiento...\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\" min=\"1910-07-01\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientssnumber elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientssnumber\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSSN\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientssnumber]\" id=\"form-field-personalpatientssnumber\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de seguro social...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-pdoffice elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-pdoffice\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOficina Preferida\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[pdoffice]\" id=\"form-field-pdoffice\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rose Park\">Rose Park<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Union Park\">Union Park<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Jordan\">West Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Valley\">West Valley<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientsex elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientsex\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSexo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientsex]\" id=\"form-field-personalpatientsex\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Male\">Masculino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Female\">Femenino<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientstatus elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientstatus\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEstado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientstatus]\" id=\"form-field-personalpatientstatus\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minor\">Menor<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Single\">Soltero<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Married\">Casado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorced\">Divorciado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Widowed\">Viudo<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientmailinadd elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientmailinadd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientmailinadd]\" id=\"form-field-personalpatientmailinadd\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Direcci\u00f3n de envio...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientstate elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientstate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEstado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientstate]\" id=\"form-field-personalpatientstate\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alabama\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alaska\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arizona\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arkansas\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"California\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colorado\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Connecticut\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delaware\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Florida\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hawaii\">Hawai<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Idaho\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Illinois\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indiana\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iowa\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kansas\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kentucky\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Louisiana\">Luisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maine\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maryland\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Massachusetts\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Michigan\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minnesota\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mississippi\">Misisip\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Missouri\">Misuri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montana\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nebraska\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nevada\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Hampshire\">Nuevo Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Jersey\">Nueva Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Mexico\">Nuevo M\u00e9jico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New York\">Nueva York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Carolina\">Carolina del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Dakota\">Dakota del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ohio\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oklahoma\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oregon\">Oreg\u00f3n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pennsylvania\">Pensilvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rhode Island\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Carolina\">Carolina del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Dakota\">Dakota del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tennessee\">Tennesse<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texas\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Utah\" selected=\"selected\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vermont\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virginia\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Washington\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Virginia\">Virginia Occidental<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wisconsin\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wyoming\">Wyoming<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-personalpatientcity elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientcity\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[personalpatientcity]\" id=\"form-field-personalpatientcity\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpine\">alpino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Fork\">Tenedor americano<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Blanding\">Mezclado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bluffdale\">Bluffdale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brigham City\">Ciudad de Brigham<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cedar City\">Ciudad de cedro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clearfield\">Campo claro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clinton\">Clinton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cottonwood Heights\">Alturas de Cottonwood<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ephraim\">Efra\u00edn<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Farmington\">Farmington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grantsville\">Subvenciones<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heber City\">Ciudad de Heber<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Highland\">Tierras altas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holladay\">D\u00eda de fiesta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hurricane\">Hurac\u00e1n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ivins\">Ivins<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kaysville\">Kaysville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lindon\">Lindon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Magna\">Magna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mapleton\">Arceton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Midvale\">Valle medio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moab\">Moab<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Murray\">Murray<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nephi\">Nefi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Logan\">Logan del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Ogden\">Ogden del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ogden\">Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Park City\">Ciudad del parque<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Price\">Precio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Provo\">Miembro del ira provisional<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Richfield\">Campo rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roosevelt\">Roosevelt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roy\">Roy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Salt Lake City\">Ciudad del lago salado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sandy\">Arenoso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Santa Clara\">Santa Clara<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Smithfield\">Campo Smith<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Jordan\">Jordania del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Ogden\">Ogden del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish Fork\">Tenedor espa\u00f1ol<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"St. George\">San Jorge<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taylorsville\">Taylorsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tooele\">Tooele<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vernal\">Vernal<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-persozip elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-persozip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[persozip]\" id=\"form-field-persozip\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"C\u00f3digo postal...\" required=\"required\" min=\"\" max=\"99999\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatienthomephone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatienthomephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de casa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatienthomephone]\" id=\"form-field-personalpatienthomephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono de casa...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientworkphone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientworkphone]\" id=\"form-field-personalpatientworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientcellphone elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientcellphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono m\u00f3vil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientcellphone]\" id=\"form-field-personalpatientcellphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono m\u00f3vil...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-personalpatientemail elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientemail\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n de correo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[personalpatientemail]\" id=\"form-field-personalpatientemail\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Correo electr\u00f3nico...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalpatientemployer elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalpatientemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmpleo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalpatientemployer]\" id=\"form-field-personalpatientemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Empleador...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalcontactemergency elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalcontactemergency\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tContacto de Emergencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalcontactemergency]\" id=\"form-field-personalcontactemergency\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del contacto de emergencia...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-personalemergencyphone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalemergencyphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00famero de tel\u00e9fono de emergencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[personalemergencyphone]\" id=\"form-field-personalemergencyphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de tel\u00e9fono de emergencia...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-personalhowhear elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-personalhowhear\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfC\u00f3mo se enter\u00f3 de nosotros?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Instagram \" id=\"form-field-personalhowhear-0\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-0\">Instagram <\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Facebook\" id=\"form-field-personalhowhear-1\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-1\">Facebook<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Google\" id=\"form-field-personalhowhear-2\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-2\">Google<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Website\" id=\"form-field-personalhowhear-3\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-3\">Sitio Web<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Insurance\" id=\"form-field-personalhowhear-4\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-4\">Seguro<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Family \/ Friend\" id=\"form-field-personalhowhear-5\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-5\">Familia \/ Amigo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Other\" id=\"form-field-personalhowhear-6\" name=\"form_fields[personalhowhear]\" required=\"required\"> <label for=\"form-field-personalhowhear-6\">Otro<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-fullnamefamilyfriend elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-fullnamefamilyfriend\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre completo del familiar\/amigo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[fullnamefamilyfriend]\" id=\"form-field-fullnamefamilyfriend\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre completo del familiar\/amigo\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-otherreferral elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-otherreferral\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tOtra referencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[otherreferral]\" id=\"form-field-otherreferral\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Otra referencia\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-responsibletitle elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-guarantoroftheaccount elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-guarantoroftheaccount\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEs usted el garante de la cuenta?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[guarantoroftheaccount]\" id=\"form-field-guarantoroftheaccount\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responname elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responname\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre del garante de la cuenta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responname]\" id=\"form-field-responname\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del garante...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responrelation elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responrelation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responrelation]\" id=\"form-field-responrelation\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Relaci\u00f3n con el paciente...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responmail elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responmail\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responmail]\" id=\"form-field-responmail\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Direcci\u00f3n postal...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-responstate elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responstate\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEstado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[responstate]\" id=\"form-field-responstate\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alabama\">Alabama<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alaska\">Alaska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arizona\">Arizona<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Arkansas\">Arkansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"California\">California<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Colorado\">Colorado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Connecticut\">Connecticut<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delaware\">Delaware<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Florida\">Florida<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Georgia\">Georgia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hawaii\">Hawai<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Idaho\">Idaho<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Illinois\">Illinois<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Indiana\">Indiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Iowa\">Iowa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kansas\">Kansas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kentucky\">Kentucky<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Louisiana\">Luisiana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maine\">Maine<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Maryland\">Maryland<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Massachusetts\">Massachusetts<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Michigan\">Michigan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Minnesota\">Minnesota<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mississippi\">Misisip\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Missouri\">Misuri<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Montana\">Montana<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nebraska\">Nebraska<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nevada\">Nevada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Hampshire\">Nuevo Hampshire<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Jersey\">Nueva Jersey<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New Mexico\">Nuevo M\u00e9jico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"New York\">Nueva York<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Carolina\">Carolina del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Dakota\">Dakota del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ohio\">Ohio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oklahoma\">Oklahoma<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Oregon\">Oreg\u00f3n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pennsylvania\">Pensilvania<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Rhode Island\">Rhode Island<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Carolina\">Carolina del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Dakota\">Dakota del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tennessee\">Tennesse<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Texas\">Texas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Utah\" selected=\"selected\">Utah<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vermont\">Vermont<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Virginia\">Virginia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Washington\">Washington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Virginia\">Virginia Occidental<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wisconsin\">Wisconsin<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Wyoming\">Wyoming<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-responcity elementor-col-20 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responcity\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCiudad\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[responcity]\" id=\"form-field-responcity\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Alpine\">alpino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"American Fork\">Tenedor americano<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Blanding\">Mezclado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bluffdale\">Bluffdale<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Bountiful\">Bountiful<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Brigham City\">Ciudad de Brigham<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cedar City\">Ciudad de cedro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clearfield\">Campo claro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clinton\">Clinton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cottonwood Heights\">Alturas de Cottonwood<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ephraim\">Efra\u00edn<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Farmington\">Farmington<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Grantsville\">Subvenciones<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Heber City\">Ciudad de Heber<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Highland\">Tierras altas<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Holladay\">D\u00eda de fiesta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hurricane\">Hurac\u00e1n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ivins\">Ivins<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Kaysville\">Kaysville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lindon\">Lindon<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Magna\">Magna<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mapleton\">Arceton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Midvale\">Valle medio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Millcreek\">Millcreek<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Moab\">Moab<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Murray\">Murray<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nephi\">Nefi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Logan\">Logan del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"North Ogden\">Ogden del Norte<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ogden\">Ogden<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Park City\">Ciudad del parque<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Price\">Precio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Provo\">Miembro del ira provisional<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Richfield\">Campo rico<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roosevelt\">Roosevelt<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Roy\">Roy<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Salt Lake City\">Ciudad del lago salado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sandy\">Arenoso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Santa Clara\">Santa Clara<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Smithfield\">Campo Smith<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Jordan\">Jordania del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"South Ogden\">Ogden del Sur<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spanish Fork\">Tenedor espa\u00f1ol<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"St. George\">San Jorge<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Taylorsville\">Taylorsville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Tooele\">Tooele<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Vernal\">Vernal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Otro<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-responzip elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responzip\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tC\u00f3digo postal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[responzip]\" id=\"form-field-responzip\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"C\u00f3digo postal...\" required=\"required\" min=\"\" max=\"99999\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responphone elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de casa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responphone]\" id=\"form-field-responphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono de casa...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-respworkphone elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-respworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[respworkphone]\" id=\"form-field-respworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-respcellphone elementor-col-33 elementor-sm-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-respcellphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono m\u00f3vil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[respcellphone]\" id=\"form-field-respcellphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono m\u00f3vil...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-responbirth elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responbirth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[responbirth]\" id=\"form-field-responbirth\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Nacimiento\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responemployer elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmpleo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responemployer]\" id=\"form-field-responemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del empleador...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-responss elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responss\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00famero de Seguro Social #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[responss]\" id=\"form-field-responss\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de seguro social...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-responpayment elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-responpayment\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tM\u00e9todo de pago preferido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cash\" id=\"form-field-responpayment-0\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-0\">Dinero<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Personal Check\" id=\"form-field-responpayment-1\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-1\">Cheque personal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Credit Card\" id=\"form-field-responpayment-2\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-2\">Tarjeta de cr\u00e9dito<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"CareCredit\" id=\"form-field-responpayment-3\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-3\">Cr\u00e9dito de atenci\u00f3n<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Others\" id=\"form-field-responpayment-4\" name=\"form_fields[responpayment][]\"> <label for=\"form-field-responpayment-4\">Otros<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-insuranceinfo elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-doyouhaveinsurance elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-doyouhaveinsurance\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTiene usted seguro?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[doyouhaveinsurance]\" id=\"form-field-doyouhaveinsurance\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0069474 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0069474\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre del seguro\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0069474]\" id=\"form-field-field_0069474\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del seguro...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancegroup elementor-col-25 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancegroup\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGrupo #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancegroup]\" id=\"form-field-insurancegroup\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de grupo...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceid elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceid\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIdentificaci\u00f3n #\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceid]\" id=\"form-field-insuranceid\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de identificaci\u00f3n...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancephone elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tN\u00famero de tel\u00e9fono del seguro\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancephone]\" id=\"form-field-insurancephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de tel\u00e9fono del seguro...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceaddress elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceaddress\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDirecci\u00f3n de seguros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceaddress]\" id=\"form-field-insuranceaddress\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Direcci\u00f3n de seguro...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancepolicyholder elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancepolicyholder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre del titular de la p\u00f3liza\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancepolicyholder]\" id=\"form-field-insurancepolicyholder\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del titular de la p\u00f3liza...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-insurancedobpolicyholder elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancedobpolicyholder\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFecha de nacimiento del titular de la p\u00f3liza\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[insurancedobpolicyholder]\" id=\"form-field-insurancedobpolicyholder\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field elementor-use-native\" placeholder=\"Fecha de nacimiento del titular de la p\u00f3liza...\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insurancessn elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancessn\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSSN#\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insurancessn]\" id=\"form-field-insurancessn\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"N\u00famero de seguro social...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceemployer elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceemployer\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEmpleo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceemployer]\" id=\"form-field-insuranceemployer\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Empleador...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-insuranceworkphone elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insuranceworkphone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono del trabajo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[insuranceworkphone]\" id=\"form-field-insuranceworkphone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono del trabajo...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-insurancerelationshiptopatient elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-insurancerelationshiptopatient\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[insurancerelationshiptopatient]\" id=\"form-field-insurancerelationshiptopatient\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"It&#039;s me\">Soy yo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Parent\">Padre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guardian \/ Tutor\">Tutor \/ Guardi\u00e1n<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Spouse \">C\u00f3nyuge <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Son \/ Daughter\">Hijo\/Hija<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Other\">Otro<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-medicalhistory elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalphysician elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalphysician\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre del m\u00e9dico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalphysician]\" id=\"form-field-medicalphysician\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre del m\u00e9dico\/doctor...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalofficephone elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalofficephone\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTel\u00e9fono de la oficina\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalofficephone]\" id=\"form-field-medicalofficephone\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Tel\u00e9fono de la oficina\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-medicaldateoflastvisit elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaldateoflastvisit\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFecha de la \u00faltima visita\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[medicaldateoflastvisit]\" id=\"form-field-medicaldateoflastvisit\" class=\"elementor-field elementor-size-md  elementor-field-textual elementor-date-field\" placeholder=\"Fecha de la \u00faltima visita...\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltreatment elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltreatment\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1 usted bajo tratamiento m\u00e9dico actualmente?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltreatment]\" id=\"form-field-medicaltreatment\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalundertreatexplain elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalundertreatexplain\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPor favor explique\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalundertreatexplain]\" id=\"form-field-medicalundertreatexplain\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Por favor explique...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalhospitalized elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalhospitalized\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfHa sido usted hospitalizado en los \u00faltimos 5 a\u00f1os?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalhospitalized]\" id=\"form-field-medicalhospitalized\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalhospitalizedexplain elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalhospitalizedexplain\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPor favor explique\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalhospitalizedexplain]\" id=\"form-field-medicalhospitalizedexplain\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Por favor explique...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltakingmedications elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltakingmedications\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1 tomando medicamentos, incluidos anticoagulantes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltakingmedications]\" id=\"form-field-medicaltakingmedications\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_078ca55 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_078ca55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPor favor explique\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_078ca55]\" id=\"form-field-field_078ca55\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Por favor explique...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalbisphosphaonates elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalbisphosphaonates\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlguna vez has tomado bisfosfonatos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalbisphosphaonates]\" id=\"form-field-medicalbisphosphaonates\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalbisphosphaonateshowlong elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalbisphosphaonateshowlong\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1nto tiempo?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalbisphosphaonateshowlong]\" id=\"form-field-medicalbisphosphaonateshowlong\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Por cu\u00e1nto tiempo...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicaltakenphenfen elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicaltakenphenfen\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlguna vez has tomado Phen Fen?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicaltakenphenfen]\" id=\"form-field-medicaltakenphenfen\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalcontrolledsusbstances elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalcontrolledsusbstances\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUtilizar sustancias controladas?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalcontrolledsusbstances]\" id=\"form-field-medicalcontrolledsusbstances\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-medicalttobacco elementor-col-50 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalttobacco\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfUsas tabaco?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[medicalttobacco]\" id=\"form-field-medicalttobacco\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-medicalttobaccohowlong elementor-col-50 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-medicalttobaccohowlong\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfC\u00f3mo se usa y por cu\u00e1nto tiempo?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[medicalttobaccohowlong]\" id=\"form-field-medicalttobaccohowlong\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"\u00bfC\u00f3mo se usa y por cu\u00e1nto tiempo?\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-allergictoanyofthefollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-allergictoanyofthefollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEs usted al\u00e9rgico o ha tenido alguna reacci\u00f3n a lo siguiente?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Local Anesthetics\" id=\"form-field-allergictoanyofthefollowing-0\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-0\">Anest\u00e9sicos locales<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Penicilin \/ Antibiotics\" id=\"form-field-allergictoanyofthefollowing-1\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-1\">Penicilina \/ Antibi\u00f3ticos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Latex Rubber\" id=\"form-field-allergictoanyofthefollowing-2\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-2\">Caucho de l\u00e1tex<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Any Metals\" id=\"form-field-allergictoanyofthefollowing-3\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-3\">Cualquier metal<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Codeine\" id=\"form-field-allergictoanyofthefollowing-4\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-4\">Code\u00edna<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Other\" id=\"form-field-allergictoanyofthefollowing-5\" name=\"form_fields[allergictoanyofthefollowing][]\"> <label for=\"form-field-allergictoanyofthefollowing-5\">Otro<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-haveanyofthefollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-haveanyofthefollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTiene actualmente o ha tenido alguna vez alguno de los siguientes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"High Blood Pressure\" id=\"form-field-haveanyofthefollowing-0\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-0\">Hipertensi\u00f3n<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Diabetes \" id=\"form-field-haveanyofthefollowing-1\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-1\">Diabetes <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Murmur \" id=\"form-field-haveanyofthefollowing-2\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-2\">Soplo card\u00edaco <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Mitral Valve Prolapse\" id=\"form-field-haveanyofthefollowing-3\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-3\">Prolapso de la v\u00e1lvula mitral<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Seizures \" id=\"form-field-haveanyofthefollowing-4\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-4\">Convulsiones <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anemia \" id=\"form-field-haveanyofthefollowing-5\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-5\">Anemia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Thyroid Problems \" id=\"form-field-haveanyofthefollowing-6\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-6\">Problemas de tiroides <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Tuberculosis\" id=\"form-field-haveanyofthefollowing-7\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-7\">Tuberculosis<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Liver Disease \" id=\"form-field-haveanyofthefollowing-8\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-8\">Enfermedad del h\u00edgado <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cardiac Pacemaker \" id=\"form-field-haveanyofthefollowing-9\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-9\">Marcapasos card\u00edaco <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Rheumatic Fever \" id=\"form-field-haveanyofthefollowing-10\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-10\">Fiebre reum\u00e1tica <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Kidney Disease\" id=\"form-field-haveanyofthefollowing-11\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-11\">Nefropat\u00eda<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Emphysema \" id=\"form-field-haveanyofthefollowing-12\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-12\">Enfisema <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"STD \" id=\"form-field-haveanyofthefollowing-13\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-13\">ETS <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Glaucoma \" id=\"form-field-haveanyofthefollowing-14\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-14\">Glaucoma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Radiation Therapy\" id=\"form-field-haveanyofthefollowing-15\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-15\">Radioterapia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Low Blood\" id=\"form-field-haveanyofthefollowing-16\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-16\">Presi\u00f3n arterial baja<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pressure\" id=\"form-field-haveanyofthefollowing-17\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-17\">Presi\u00f3n<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Attack \" id=\"form-field-haveanyofthefollowing-18\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-18\">Infarto de miocardio <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Swollen Ankles \" id=\"form-field-haveanyofthefollowing-19\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-19\">Tobillos hinchados <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Epilepsy \/ Convulsions\" id=\"form-field-haveanyofthefollowing-20\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-20\">Epilepsia \/ Convulsiones<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Asthma \" id=\"form-field-haveanyofthefollowing-21\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-21\">Asma <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"AIDS\/HIV \" id=\"form-field-haveanyofthefollowing-22\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-22\">SIDA\/VIH <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stroke\" id=\"form-field-haveanyofthefollowing-23\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-23\">Ataque<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fainting\" id=\"form-field-haveanyofthefollowing-24\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-24\">Desmayo<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Heart Disease\" id=\"form-field-haveanyofthefollowing-25\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-25\">Cardiopat\u00eda<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Respiratory Problems \" id=\"form-field-haveanyofthefollowing-26\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-26\">Problemas respiratorios <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Leukemia \" id=\"form-field-haveanyofthefollowing-27\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-27\">Leucemia <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Cancer\" id=\"form-field-haveanyofthefollowing-28\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-28\">C\u00e1ncer<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Joint Replacement\" id=\"form-field-haveanyofthefollowing-29\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-29\">Reemplazo de articulaci\u00f3n<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Stomach Problems \" id=\"form-field-haveanyofthefollowing-30\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-30\">Problemas de est\u00f3mago <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hay Fever\/ Allergies \" id=\"form-field-haveanyofthefollowing-31\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-31\">Fiebre del heno\/Alergias <\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Hepatitis\/Jaundice\" id=\"form-field-haveanyofthefollowing-32\" name=\"form_fields[haveanyofthefollowing][]\"> <label for=\"form-field-haveanyofthefollowing-32\">Hepatitis\/ictericia<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_efb8361 elementor-col-100\">\n\t\t\t\t\tDormir y respirar\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwaktired elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwaktired\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfSuele despertarse sinti\u00e9ndose cansado?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwaktired]\" id=\"form-field-sleepingwaktired\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingsnore elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingsnore\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfRoncas habitualmente?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingsnore]\" id=\"form-field-sleepingsnore\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwakingheadeaches elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwakingheadeaches\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfLos dolores de cabeza te despiertan con frecuencia?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwakingheadeaches]\" id=\"form-field-sleepingwakingheadeaches\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingdrownsiness elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingdrownsiness\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfExperimenta usted somnolencia durante el d\u00eda?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingdrownsiness]\" id=\"form-field-sleepingdrownsiness\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingstopbreathing elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingstopbreathing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlguien te ha observado dejar de respirar mientras duermes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingstopbreathing]\" id=\"form-field-sleepingstopbreathing\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingblocknasal elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingblocknasal\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTiene los conductos nasales bloqueados?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingblocknasal]\" id=\"form-field-sleepingblocknasal\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepinggrindteeth elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepinggrindteeth\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfRechinas los dientes mientras duermes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepinggrindteeth]\" id=\"form-field-sleepinggrindteeth\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-sleepingwakechoking elementor-col-33 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-sleepingwakechoking\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfAlguna vez te despiertas ahog\u00e1ndote o jadeando?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[sleepingwakechoking]\" id=\"form-field-sleepingwakechoking\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_94244ef elementor-col-100\">\n\t\t\t\t\tSolo mujeres\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womenpregnant elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womenpregnant\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1s embarazada o crees que podr\u00edas estar embarazada?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womenpregnant]\" id=\"form-field-womenpregnant\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womennursing elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womennursing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEst\u00e1s amamantando?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womennursing]\" id=\"form-field-womennursing\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-womencontraceptives elementor-col-33 elementor-sm-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-womencontraceptives\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfEstas tomando anticonceptivos?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[womencontraceptives]\" id=\"form-field-womencontraceptives\" class=\"elementor-field-textual elementor-size-md\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0961b63 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dentalpreviousdentist elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalpreviousdentist\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDentista anterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dentalpreviousdentist]\" id=\"form-field-dentalpreviousdentist\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Dentista anterior...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-dentalpreviousclinic elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalpreviousclinic\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCl\u00ednica anterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[dentalpreviousclinic]\" id=\"form-field-dentalpreviousclinic\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre de la cl\u00ednica anterior...\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentaltimesbrush elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentaltimesbrush\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1ntas veces al d\u00eda te cepillas los dientes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentaltimesbrush]\" id=\"form-field-dentaltimesbrush\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentaltimesfloss elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentaltimesfloss\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfCu\u00e1ntas veces a la semana usas hilo dental?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentaltimesfloss]\" id=\"form-field-dentaltimesfloss\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"More\">M\u00e1s<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentalratesmile elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalratesmile\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfC\u00f3mo calificar\u00edas tu sonrisa?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentalratesmile]\" id=\"form-field-dentalratesmile\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6\">6<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7\">7<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8\">8<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9\">9<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10\">10<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-dentalrequireantibiotic elementor-col-25 elementor-sm-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalrequireantibiotic\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfNecesita medicaci\u00f3n antibi\u00f3tica previa?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[dentalrequireantibiotic]\" id=\"form-field-dentalrequireantibiotic\" class=\"elementor-field-textual elementor-size-md\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Yes\">S\u00ed<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-dentalanyfollowing elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-dentalanyfollowing\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t\u00bfTiene usted alguno de los siguientes?\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Red, Swollen, Bleeding Gums\" id=\"form-field-dentalanyfollowing-0\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-0\">Enc\u00edas rojas, hinchadas y sangrantes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Pain in teeth\" id=\"form-field-dentalanyfollowing-1\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-1\">Dolor en los dientes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Teeth Sensitive to hot, cold or sweets\" id=\"form-field-dentalanyfollowing-2\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-2\">Dientes sensibles al calor, al fr\u00edo o a los dulces.<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Broken or chipped teeth or fillings\" id=\"form-field-dentalanyfollowing-3\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-3\">Dientes o empastes rotos o astillados<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Snoring\" id=\"form-field-dentalanyfollowing-4\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-4\">Ronquidos<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Anxiety\" id=\"form-field-dentalanyfollowing-5\" name=\"form_fields[dentalanyfollowing][]\"> <label for=\"form-field-dentalanyfollowing-5\">Ansiedad<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_45edc5d elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"fas fa-star\" data-icon=\"&lt;svg class=&quot;e-font-icon-svg e-fas-star&quot; viewBox=&quot;0 0 576 512&quot; xmlns=&quot;http:\/\/www.w3.org\/2000\/svg&quot;&gt;&lt;path d=&quot;M259.3 17.8L194 150.2 47.9 171.5c-26.2 3.8-36.7 36.1-17.7 54.6l105.7 103-25 145.5c-4.5 26.3 23.2 46 46.4 33.7L288 439.6l130.7 68.7c23.2 12.2 50.9-7.4 46.4-33.7l-25-145.5 105.7-103c19-18.5 8.5-50.8-17.7-54.6L382 150.2 316.7 17.8c-11.7-23.6-45.6-23.9-57.4 0z&quot;&gt;&lt;\/path&gt;&lt;\/svg&gt;\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_eb8116a elementor-col-100\">\n\t\t\t\t\tLea los formularios dentales profesionales que acepta al firmar:\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_32fba46 elementor-col-100\">\n\t\t\t\t\t<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Consent-Form-1.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Haga clic aqu\u00ed para leer el formulario de consentimiento<\/a> <br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Financial-Policy.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Haga clic aqu\u00ed para leer la pol\u00edtica financiera<\/a> <br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Notice-of-Privacy-Practice-@PD-English-2.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Haga clic aqu\u00ed para leer las pr\u00e1cticas de privacidad<\/a><br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/03\/Notice-of-Non-covered.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Haga clic aqu\u00ed para leer el aviso sobre productos y servicios dentales no cubiertos.<\/a><br>\n<a href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2026\/03\/Professional-Dental-Agreement-to-use-image-1.pdf\" style=\"color:#5EB2F2\" target=\"_blank\">Haga clic aqu\u00ed para leer el formulario de consentimiento para el uso de redes sociales.<\/a>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_57789c8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_57789c8]\" id=\"form-field-field_57789c8\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-field_57789c8\">Acepto compartir mi informaci\u00f3n con Professional Dental &amp; Orthodontics y confirmo que le\u00ed los Formularios y T\u00e9rminos y Condiciones<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-consentaccept elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[consentaccept]\" id=\"form-field-consentaccept\" class=\"elementor-field elementor-size-md  elementor-acceptance-field\" required=\"required\">\n\t\t\t\t<label for=\"form-field-consentaccept\">Entiendo y acepto el formulario de consentimiento dental profesional, la pol\u00edtica financiera, las pr\u00e1cticas de privacidad y el aviso de productos y servicios dentales no cubiertos<\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a0e077b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a0e077b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tNombre completo (su nombre es v\u00e1lido al igual que su firma)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a0e077b]\" id=\"form-field-field_a0e077b\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Nombre completo como se muestra en la identificaci\u00f3n...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-consentrelation elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-consentrelation\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRelaci\u00f3n con el paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[consentrelation]\" id=\"form-field-consentrelation\" class=\"elementor-field elementor-size-md  elementor-field-textual\" placeholder=\"Relaci\u00f3n con el paciente...\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-dce_form_signature elementor-field-group elementor-column elementor-field-group-signatureprivacy elementor-col-40 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-signatureprivacy\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFirma digital\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div style=\"width: 100%; display: block;\">\n\t\t\t<div class=\"dce-signature-wrapper\" style=\"width: var(--canvas-width); min-width: 200px;\">\n\t\t\t\t<div style=\"position: relative; display: inline-block; width: 100%;\">\n\t\t\t\t\t<button type=\"button\"\n\t\t\t\t\t\t\tclass=\"dce-signature-button-clear\"\n\t\t\t\t\t\t\tdata-action=\"clear\"\n\t\t\t\t\t\t\tstyle=\"position: absolute; top: 0; right: 0; z-index: 10;\">\n\t\t\t\t\t\t<svg class=\"e-font-icon-svg e-eicon-close\" viewbox=\"0 0 1000 1000\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M742 167L500 408 258 167C246 154 233 150 217 150 196 150 179 158 167 167 154 179 150 196 150 212 150 229 154 242 171 254L408 500 167 742C138 771 138 800 167 829 196 858 225 858 254 829L496 587 738 829C750 842 767 846 783 846 800 846 817 842 829 829 842 817 846 804 846 783 846 767 842 750 829 737L588 500 833 258C863 229 863 200 833 171 804 137 775 137 742 167Z\"><\/path><\/svg>\t\t\t\t\t<\/button>\n\t\t\t\t\t<input type=\"dce_form_signature\" name=\"form_fields[signatureprivacy]\" id=\"form-field-signatureprivacy\" class=\"elementor-field elementor-size-md\" required=\"required\" style=\"width: 0; height: 0; opacity: 0; position: absolute; pointer-events: none;\">\n\t\t\t\t\t<canvas class=\"dce-signature-canvas\" data-pen-color=\"#000000\" data-background-color=\"#ffffff\" data-jpeg=\"no\" data-aspect-ratio=\"2\" width=\"1\" height=\"1\" style=\"width: 100%; height: calc(100% \/ 2); border-style: solid; touch-action: none; user-select: none;\"><\/canvas>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t\t\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-paper-plane\" viewbox=\"0 0 512 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M476 3.2L12.5 270.6c-18.1 10.4-15.8 35.6 2.2 43.2L121 358.4l287.3-253.2c5.5-4.9 13.3 2.6 8.6 8.3L176 407v80.5c0 23.6 28.5 32.9 42.5 15.8L282 426l124.6 52.2c14.2 6 30.4-2.9 33-18.2l72-432C515 7.8 493.3-6.8 476 3.2z\"><\/path><\/svg>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">ENTREGAR<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t<style>.elementor-element.elementor-element-8cd5c9e .elementor-field-group { align-self: flex-start; }<\/style>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-078fce0 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"078fce0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Al enviar este formulario, usted acepta compartir su informaci\u00f3n personal, m\u00e9dica y de seguro con Professional Dental. Si tiene alguna pregunta, ll\u00e1menos al 801-785-8000.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-707a77f e-flex e-con-boxed e-con e-parent\" data-id=\"707a77f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0e792c7 elementor-widget elementor-widget-spacer\" data-id=\"0e792c7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\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<div data-dce-background-overlay-color=\"#2C5D83\" class=\"elementor-element elementor-element-e45e368 e-con-full e-flex elementor-invisible e-con e-parent\" data-id=\"e45e368\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-7162255 e-flex e-con-boxed elementor-invisible e-con e-child\" data-id=\"7162255\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:100}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0788c12 elementor-widget elementor-widget-heading\" data-id=\"0788c12\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">\u00bfPrefieres el papel? <\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4868867 elementor-widget elementor-widget-ucaddon_dual_color_heading\" data-id=\"4868867\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_dual_color_heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Dual Color Heading -->\n\n<div class=\"ue-dual-color-heading\">\n  <h3>\n    <span class=\"ue-title-one\">Descargar todos los <\/span> <span class=\"ue-title-two\">Formularios y L\u00e9elos Cuidadosamente<\/span>\n  <\/h3>\n<\/div>\n<!-- end Dual Color Heading -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bb75dfe elementor-widget elementor-widget-heading\" data-id=\"bb75dfe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\">Todos los pacientes deben leer cuidadosamente y aceptar nuestros T\u00e9rminos y Condiciones, y firmar nuestro Formulario de Consentimiento, Pol\u00edtica Financiera y Pol\u00edtica de Privacidad.<\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-b918233 e-con-full e-flex e-con e-child\" data-id=\"b918233\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6432ef4 elementor-widget elementor-widget-button\" data-id=\"6432ef4\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2026\/01\/Printing-New-Patient-Form-PD-12-16-2025-1-1.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-cloud-download-alt\" viewbox=\"0 0 640 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M537.6 226.6c4.1-10.7 6.4-22.4 6.4-34.6 0-53-43-96-96-96-19.7 0-38.1 6-53.3 16.2C367 64.2 315.3 32 256 32c-88.4 0-160 71.6-160 160 0 2.7.1 5.4.2 8.1C40.2 219.8 0 273.2 0 336c0 79.5 64.5 144 144 144h368c70.7 0 128-57.3 128-128 0-61.9-44-113.6-102.4-125.4zm-132.9 88.7L299.3 420.7c-6.2 6.2-16.4 6.2-22.6 0L171.3 315.3c-10.1-10.1-2.9-27.3 11.3-27.3H248V176c0-8.8 7.2-16 16-16h48c8.8 0 16 7.2 16 16v112h65.4c14.2 0 21.4 17.2 11.3 27.3z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Formulario de Nuevo Paciente<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bfc50f8 elementor-widget elementor-widget-button\" data-id=\"bfc50f8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2025\/01\/Financial-Policy.pdf\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-cloud-download-alt\" viewbox=\"0 0 640 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M537.6 226.6c4.1-10.7 6.4-22.4 6.4-34.6 0-53-43-96-96-96-19.7 0-38.1 6-53.3 16.2C367 64.2 315.3 32 256 32c-88.4 0-160 71.6-160 160 0 2.7.1 5.4.2 8.1C40.2 219.8 0 273.2 0 336c0 79.5 64.5 144 144 144h368c70.7 0 128-57.3 128-128 0-61.9-44-113.6-102.4-125.4zm-132.9 88.7L299.3 420.7c-6.2 6.2-16.4 6.2-22.6 0L171.3 315.3c-10.1-10.1-2.9-27.3 11.3-27.3H248V176c0-8.8 7.2-16 16-16h48c8.8 0 16 7.2 16 16v112h65.4c14.2 0 21.4 17.2 11.3 27.3z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Pol\u00edtica Financiera<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6fd6e56 elementor-widget elementor-widget-text-editor\" data-id=\"6fd6e56\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u00bfTienes alguna pregunta? Ll\u00e1manos para m\u00e1s informaci\u00f3n <a href=\"tel:8017858000\">(801) 785 &#8211; 8000<\/a>Estamos aqu\u00ed para ayudar.<\/p>\t\t\t\t\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<div class=\"elementor-element elementor-element-a92ecf2 e-flex e-con-boxed elementor-invisible e-con e-child\" data-id=\"a92ecf2\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:150}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-07T150116.247.jpg\" class=\"elementor-element elementor-element-9c904e7 elementor-widget elementor-widget-ucaddon_blox_play_button\" data-id=\"9c904e7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_blox_play_button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Video Play Button -->\n\t\t<link id='font-awesome-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/font-awesome6\/fontawesome-all.min.css' type='text\/css' rel='stylesheet' >\n\t\t<link id='font-awesome-4-shim-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/font-awesome6\/fontawesome-v4-shims.min.css' type='text\/css' rel='stylesheet' >\n\t\t<link id='lity-css' href='https:\/\/prodentalut.com\/wp-content\/plugins\/unlimited-elements-for-elementor-premium\/assets_libraries\/lity\/lity.min.css' type='text\/css' rel='stylesheet' >\n\n<style>\/* widget: Video Play Button *\/\n\n#uc_blox_play_button_elementor_9c904e7\n{\n width:100%;\n}\n.container_uc_blox_play_button_elementor_9c904e7{\n  display: flex;\n  justify-content: center;\n}\n\n#uc_blox_play_button_elementor_9c904e7 a\n{\n  display:inline-block;\n  transition:0.5s;\n  text-decoration:none;\n}\n.ue_play_button{text-align:center;}\n\n#uc_blox_play_button_elementor_9c904e7 a:hover\n{\n  transform:scale(1.1,1.1);\n}\n\n#uc_blox_play_button_elementor_9c904e7 a span.video-button\n{\n  display:inline-block;\n  align-items: center;\n  justify-content: center;\n  flex-direction: column; \n  display:flex;\n  position:relative;\n  transition:0.3s;\n  line-height:1em;\n}\n\n.ue-play-bg{\n  background-size:cover;\n  background-position:center;\n  background-repeat:none;\n  max-width:100%; \n}\n\n#uc_blox_play_button_elementor_9c904e7 a span.video-button svg\n{\n  height:1em;\n  width:1em;\n}\n\n#uc_blox_play_button_elementor_9c904e7 i\n{\n\n  vertical-align:middle;\n  transition:0.3s;\n}\n\n#uc_blox_play_button_elementor_9c904e7 a span:before\n{\n  content: '';\n    display: inline-block;\n    position: absolute;\n    top: -2px;\n    left: -2px;\n    bottom: -2px;\n    right: -2px;\n    border-radius: inherit;\n    border: 1px solid #F1F7FC;\n    -webkit-animation: btnIconRipple 2s cubic-bezier(0.23, 1, 0.32, 1) both infinite;\n    animation: btnIconRipple 2s cubic-bezier(0.23, 1, 0.32, 1) both infinite;\n    border-color: #F1F7FC;\n}\n\n@keyframes btnIconRipple {\n  0% {\n    border-width: 4px;\n            transform: scale(1);\n  }\n  80% {\n    border-width: 1px;\n            transform: scale(1.35);\n  }\n  100% {\n    opacity: 0;\n  }\n}\n\n\n.ue-play-bg\n{\n  display:flex;\n  align-items:center;\n  justify-content:center;\n}\n\n\n\n\n\n\n\n\n\n\n\t\t  .button_uc_blox_play_button_elementor_9c904e7{\n          animation: ue-video-popup-waggle 5s infinite;\n      }\n\n      @keyframes ue-video-popup-waggle {\n          0% {\n              transform: none;\n          }\n\n          10% {\n              transform: rotateZ(-20deg) scale(1.2);\n          }\n\n          13% {\n              transform: rotateZ(25deg) scale(1.2);\n          }\n\n          15% {\n              transform: rotateZ(-15deg) scale(1.2);\n          }\n\n          17% {\n              transform: rotateZ(15deg) scale(1.2);\n          }\n\n          20% {\n              transform: rotateZ(-12deg) scale(1.2);\n          }\n\n          22% {\n              transform: rotateZ(0) scale(1.2);\n          }\n\n          25%,\n          100% {\n              transform: rotateZ(0) scale(1);\n          }\n      }\n\t\n\t\t\n\t\n\t\n\t\n\t\n\t\n\n.lity-close{\n  display: flex;\n  align-items: center;\n  justify-content: center;\n  padding:0!important;\n  color:;\n  font-size: !important;\n  background-color:;\n      }\n.lity-close *{\n  transition: all 200ms;\n}\n.lity-close:hover{\n  background-color:;\n  color:;\n}\n@media (max-width: 767px) {\n .lity-close{\n    font-size: !important;\n  }\n}\n@media (max-width: 1024px) {\n .lity-close{\n    font-size: !important;\n  }\n}\n\n<\/style>\n\n  <div class=\"container_uc_blox_play_button_elementor_9c904e7\">\n     <div class=\"ue-play-bg\" id=\"ue-play-bg_uc_blox_play_button_elementor_9c904e7\" style=\"--imgurl: url(https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/08\/Untitled-design-2024-08-07T150116.247.jpg); background-image: linear-gradient(#0000000D, #0000000D), var(--imgurl);\">\n\t\n     <div id=\"uc_blox_play_button_elementor_9c904e7\" class=\"ue_play_button\" data-path=\"\/\/www.youtube.com\/watch?v=\">\n          <a href=\"\/\/www.youtube.com\/watch?v=RG9w71TJQ64&autoplay=0&mute=1\" class=\"button_uc_blox_play_button_elementor_9c904e7\" data-lity>\n         <span class=\"video-button\">\n          <i class='fas fa-play'><\/i>\n  <\/span>  \n<\/a>\n<\/div>\n<\/div><\/div>\n<!-- end Video Play Button -->\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<div class=\"elementor-element elementor-element-49c116d e-flex e-con-boxed elementor-invisible e-con e-parent\" data-id=\"49c116d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-72b0238 e-con-full e-flex e-con e-child\" data-id=\"72b0238\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-35be9a1 elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"35be9a1\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tACEPTAMOS LA MAYORIA DE LOS SEGUROS DENTALES\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-a5b5b5c elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"a5b5b5c\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Seguros Dentales que Aceptamos\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-a2815c8 elementor-grid-5 elementor-grid-mobile-2 elementor-grid-tablet-2 elementor-invisible elementor-widget elementor-widget-loop-grid\" data-id=\"a2815c8\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;template_id&quot;:1480,&quot;columns&quot;:5,&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:300,&quot;columns_mobile&quot;:2,&quot;row_gap_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:15,&quot;sizes&quot;:[]},&quot;_skin&quot;:&quot;post&quot;,&quot;columns_tablet&quot;:&quot;2&quot;,&quot;edit_handle_selector&quot;:&quot;[data-elementor-type=\\&quot;loop-item\\&quot;]&quot;,&quot;row_gap&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;row_gap_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"loop-grid.post\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-loop-container elementor-grid\" role=\"list\">\n\t\t<style id=\"loop-1480\">.elementor-1480 .elementor-element.elementor-element-99d8a0a{--display:flex;}.elementor-widget-image .widget-image-caption{color:var( --e-global-color-text );font-family:var( --e-global-typography-text-font-family ), Sans-serif;font-weight:var( --e-global-typography-text-font-weight );}.elementor-1480 .elementor-element.elementor-element-eacfdb2 img{width:60%;max-width:60%;transition-duration:0.4s;}.elementor-1480 .elementor-element.elementor-element-eacfdb2:hover img{filter:brightness( 100% ) contrast( 100% ) saturate( 100% ) blur( 0px ) hue-rotate( 0deg );}<\/style>\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1506 post-1506 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13-300x133.png\" class=\"attachment-medium size-medium wp-image-1510\" alt=\"Unum logo representing Professional Dental&#039;s partnership with Unum for dental insurance in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/13.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1505 post-1505 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/12-300x133.png\" class=\"attachment-medium size-medium wp-image-1509\" alt=\"PEHP logo showcasing Professional Dental&#039;s partnership with PEHP for dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/12-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/12.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1508 post-1508 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/15-300x133.png\" class=\"attachment-medium size-medium wp-image-1512\" alt=\"DentaQuest logo representing Professional Dental\u2019s trusted insurance partnership in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/15-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/15.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1507 post-1507 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/14-300x133.png\" class=\"attachment-medium size-medium wp-image-1511\" alt=\"GEHA logo representing Professional Dental&#039;s dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/14-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/14.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1504 post-1504 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/11-300x133.png\" class=\"attachment-medium size-medium wp-image-1513\" alt=\"DMBA logo representing Professional Dental\u2019s trusted partnerships in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/11-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/11.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1479 post-1479 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2-300x133.png\" class=\"attachment-medium size-medium wp-image-1470\" alt=\"MetLife logo representing Professional Dental&#039;s partnership with MetLife for reliable dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/4-2.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1478 post-1478 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/3-4-300x133.png\" class=\"attachment-medium size-medium wp-image-1469\" alt=\"United Concordia Dental logo, representing Professional Dental&#039;s trusted partnership with United Concordia for comprehensive dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/3-4-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/3-4.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1477 post-1477 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4-300x133.png\" class=\"attachment-medium size-medium wp-image-1468\" alt=\"Cigna Dental logo, representing Professional Dental&#039;s partnership with Cigna for reliable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/2-4.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1476 post-1476 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10-300x133.png\" class=\"attachment-medium size-medium wp-image-1466\" alt=\"Aflac Dental logo, symbolizing Professional Dental&#039;s collaboration with Aflac for trusted dental insurance plans in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/10.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1475 post-1475 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9-300x133.png\" class=\"attachment-medium size-medium wp-image-1465\" alt=\"Aetna Dental logo, representing Professional Dental\u2019s partnership with Aetna for reliable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/9.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1474 post-1474 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993-300x133.png\" class=\"attachment-medium size-medium wp-image-1495\" alt=\"RELIANCE logo representing Professional Dental&#039;s collaboration with RELIANCE for dental insurance services in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-24T150736.993.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1473 post-1473 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7-300x133.png\" class=\"attachment-medium size-medium wp-image-1463\" alt=\"United Dental logo, showcasing Professional Dental\u2019s partnership for accessible and comprehensive dental insurance in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/7.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1472 post-1472 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6-300x133.png\" class=\"attachment-medium size-medium wp-image-1462\" alt=\"Delta Dental logo, representing Professional Dental\u2019s partnership for high-quality dental care and insurance options in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/6.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1471 post-1471 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1-300x133.png\" class=\"attachment-medium size-medium wp-image-1461\" alt=\"Guardian logo, representing Professional Dental\u2019s reliable dental insurance options for patients in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/5-1.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<div data-elementor-type=\"loop-item\" data-elementor-id=\"1480\" class=\"elementor elementor-1480 e-loop-item e-loop-item-1460 post-1460 insurances type-insurances status-publish hentry\" data-elementor-post-type=\"elementor_library\" data-custom-edit-handle=\"1\">\n\t\t\t<div class=\"elementor-element elementor-element-99d8a0a e-flex e-con-boxed e-con e-parent\" data-id=\"99d8a0a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-eacfdb2 elementor-invisible elementor-widget elementor-widget-image\" data-id=\"eacfdb2\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"133\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4-300x133.png\" class=\"attachment-medium size-medium wp-image-1467\" alt=\"Humana Dental logo, representing Professional Dental&#039;s partnership with Humana for dependable dental insurance coverage in Utah\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4-300x133.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/1-4.png 450w\" sizes=\"(max-width: 300px) 100vw, 300px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\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\t\t<\/div>\n\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d100d16 e-con-full e-flex e-con e-child\" data-id=\"d100d16\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div data-dce-title-color=\"#013A65\" class=\"elementor-element elementor-element-203088b elementor-widget__width-auto elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"203088b\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">\u00bfNo est\u00e1 en la lista? Lo m\u00e1s probable es que lo aceptemos.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f3ff020 elementor-invisible elementor-widget elementor-widget-button\" data-id=\"f3ff020\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-fas-long-arrow-alt-right\" viewbox=\"0 0 448 512\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M313.941 216H12c-6.627 0-12 5.373-12 12v56c0 6.627 5.373 12 12 12h301.941v46.059c0 21.382 25.851 32.09 40.971 16.971l86.059-86.059c9.373-9.373 9.373-24.569 0-33.941l-86.059-86.059c-15.119-15.119-40.971-4.411-40.971 16.971V216z\"><\/path><\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Cont\u00e1ctanos para m\u00e1s informaci\u00f3n (801) 785 \u2013 8000<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-4c4a7f6 e-flex e-con-boxed e-con e-parent\" data-id=\"4c4a7f6\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-19T221800.787-1024x427.jpg\" class=\"elementor-element elementor-element-d22b857 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"d22b857\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4c2a69a elementor-invisible elementor-widget elementor-widget-text-editor\" data-id=\"4c2a69a\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:100}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tBOLETIN INFORMATIVO\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f12254d elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"f12254d\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Sigue nuestro bolet\u00edn informativo para estar al tanto\n<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-84a6cd9 elementor-button-align-stretch elementor-invisible elementor-widget elementor-widget-form\" data-id=\"84a6cd9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;button_width&quot;:&quot;40&quot;,&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width_mobile&quot;:&quot;100&quot;,&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:250,&quot;step_type&quot;:&quot;progress_bar&quot;,&quot;dce_confirm_dialog_enabled&quot;:&quot;no&quot;,&quot;label_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;field_icon_size&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"New Form\" aria-label=\"Nueva forma\" action=\"\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"2044\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"84a6cd9\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"New Patient Form - Professional Dental\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"2044\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5d9c7dc elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-email elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tNombre Completo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Nombre Completo\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_e45e8a5 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8f15e7b elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8f15e7b\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tN\u00famero de tel\u00e9fono\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8f15e7b]\" id=\"form-field-field_8f15e7b\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"N\u00famero de tel\u00e9fono\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_33be23f elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-field_e2175fc elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e2175fc\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tCorreo electr\u00f3nico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[field_e2175fc]\" id=\"form-field-field_e2175fc\" class=\"elementor-field elementor-size-lg  elementor-field-textual\" placeholder=\"Correo electr\u00f3nico\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_4ea4c12 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"\" data-previousbutton=\"\" data-nextbutton=\"\" data-iconurl=\"\" data-iconlibrary=\"\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_71fb5be elementor-col-60 elementor-sm-100 elementor-field-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_71fb5be\" class=\"elementor-field-label elementor-screen-only\">\n\t\t\t\t\t\t\t\tUbicaci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before\">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<svg aria-hidden=\"true\" class=\"e-font-icon-svg e-eicon-caret-down\" viewbox=\"0 0 571.4 571.4\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path d=\"M571 393Q571 407 561 418L311 668Q300 679 286 679T261 668L11 418Q0 407 0 393T11 368 36 357H536Q550 357 561 368T571 393Z\"><\/path><\/svg>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_71fb5be]\" id=\"form-field-field_71fb5be\" class=\"elementor-field-textual elementor-size-lg\" required=\"required\">\n\t\t\t\t\t\t\t\t\t<option value=\"Nearest Location*\">Ubicaci\u00f3n m\u00e1s cercana*<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Centerville\">Centerville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Draper\">Draper<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Eagle Mountain\">Eagle Mountain<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Herriman\">Herriman<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Layton\">Layton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Lehi\">Lehi<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Logan\">Logan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Orem\">Orem<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Payson\">Payson<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pleasant Grove\">Pleasant Grove<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Riverton\">Riverton<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Saratoga Springs\">Saratoga Springs<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Springville\">Springville<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Jordan\">West Jordan<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"West Valley\">West Valley<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-40 e-form__buttons elementor-sm-100\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-lg\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Subscribir<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-423b4a4 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"423b4a4\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;animation&quot;:&quot;default&quot;,&quot;animation_delay&quot;:250}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-59afa91 elementor-widget elementor-widget-text-editor\" data-id=\"59afa91\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tO s\u00edguenos en nuestras redes sociales\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-54ff9c9 elementor-widget elementor-widget-ucaddon_social_icons_glare_effect\" data-id=\"54ff9c9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ucaddon_social_icons_glare_effect.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\n<!-- start Social Icons Glare Effect -->\n\n<style>\/* widget: Social Icons Glare Effect *\/\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 *{\n\n\tbox-sizing: border-box;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9{\n\tposition:relative;\n\twidth:100%;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button {\n    box-shadow: 0 0 30px 0 rgba(0, 0, 0, 0.05);\n    display: inline-block;\n    opacity: 1;\n    overflow: hidden;\n    position: relative;\n    text-align: center;\n    transition: all 0.35s cubic-bezier(0.31, -0.105, 0.43, 1.59) 0s;\n    \n}\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button::before {\n    content: \"\";\n    height: 100%;\n    left: 0%;\n    position: absolute;\n    top: 100%;\n    transition: all 0.35s;\n    width: 100%;\n}\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button i {\n    transform: scale(0.8);\n    transition: all 0.35s cubic-bezier(0.31, -0.105, 0.43, 1.59) 0s;\n    vertical-align: middle;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:focus::before, \n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:hover::before {\n    left: 0%;\n    top: 0%;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button i {\n\tcolor:#000000;\n}\n\n#uc_social_icons_glare_effect_elementor_54ff9c9 .uc_social-button:hover i {\n\tcolor:#ffffff;\n}\n\n<\/style>\n\n<div class=\"uc_stylish_social_buttons\" id=\"uc_social_icons_glare_effect_elementor_54ff9c9\"> \n    <!--uc_container_holder--> \n    <div class=\"uc_social-buttons\">\n    \t<a href=\"https:\/\/www.facebook.com\/ProfessionalDentalandOrtho\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-facebook\"><\/i><\/a>\n<a href=\"https:\/\/twitter.com\/prodentalutok\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-twitter\"><\/i><\/a>\n<a href=\"https:\/\/www.instagram.com\/professionaldentalut\/\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-instagram\"><\/i><\/a>\n<a href=\"https:\/\/www.tiktok.com\/@professionaldentalut\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-tiktok\"><\/i><\/a>\n<a href=\"https:\/\/www.linkedin.com\/company\/prodentalut\/\" class=\"uc_social-button\" target=\"_blank\" rel=\"noopener\"><i class=\"fab fa-linkedin-in\"><\/i><\/a>\n\n    <\/div>\n<\/div>\n<!-- end Social Icons Glare Effect -->\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div data-dce-background-overlay-color=\"#FD9191\" data-dce-background-image-url=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/Untitled-design-2024-06-19T221800.787-1024x427.jpg\" class=\"elementor-element elementor-element-cf02c78 e-con-full e-flex elementor-invisible e-con e-child\" data-id=\"cf02c78\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;animation&quot;:&quot;default&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-3e203d4 e-con-full e-flex e-con e-child\" data-id=\"3e203d4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a1194ea elementor-invisible elementor-widget elementor-widget-image\" data-id=\"a1194ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;}\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"512\" height=\"512\" src=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit.png\" class=\"attachment-large size-large wp-image-740\" alt=\"- Professional Dental\" srcset=\"https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit.png 512w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit-300x300.png 300w, https:\/\/prodentalut.com\/wp-content\/uploads\/2024\/06\/medical-kit-150x150.png 150w\" sizes=\"(max-width: 512px) 100vw, 512px\" title=\"- Odontolog\u00eda profesional\">\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0e93252 e-con-full e-flex e-con e-child\" data-id=\"0e93252\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aaab9c0 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"aaab9c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:150}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">L\u00ednea de emergencia:<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-8bb6665 elementor-invisible elementor-widget elementor-widget-heading\" data-id=\"8bb6665\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_animation&quot;:&quot;default&quot;,&quot;_animation_delay&quot;:200}\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<p class=\"elementor-heading-title elementor-size-default\"><a href=\"tel:8017858000\">(801) 785 - 8000<\/a><\/p>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\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>","protected":false},"excerpt":{"rendered":"<p>DIGITAL FORM Save Time By Completing The New Patient Form Online If you are a new patient, please fill out form below. Our office will have all the information when you come to your assigned clinic. Welcome to Professional Dental New Patient Form By submitting this form, you agree to share your personal, medical, and [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-2044","page","type-page","status-publish","hentry"],"office":null,"reviews":null,"user-image":null,"_links":{"self":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/comments?post=2044"}],"version-history":[{"count":46,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044\/revisions"}],"predecessor-version":[{"id":70888,"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/pages\/2044\/revisions\/70888"}],"wp:attachment":[{"href":"https:\/\/prodentalut.com\/es\/wp-json\/wp\/v2\/media?parent=2044"}],"curies":[{"name":"gracias","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}