{"id":3420,"date":"2024-04-02T17:47:56","date_gmt":"2024-04-02T17:47:56","guid":{"rendered":"https:\/\/new.drmartinrobles.com\/?page_id=3420"},"modified":"2024-04-05T19:20:56","modified_gmt":"2024-04-05T19:20:56","slug":"form","status":"publish","type":"page","link":"https:\/\/drmartinrobles.com\/en\/form\/","title":{"rendered":"Evaluation Request"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"3420\" class=\"elementor elementor-3420\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-cb1e49b elementor-section-height-min-height cs-section-content-fullwidth cs-parallax-on-scroll cs_scroll_y_100 elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"cb1e49b\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\" data-cs-parallax-y=\"100\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-3942523 dark-color\" data-id=\"3942523\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7d85662 elementor-widget elementor-widget-text-editor\" data-id=\"7d85662\" data-element_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<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_4' style='display:none'><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_4' id='gform_4'  action='\/en\/wp-json\/wp\/v2\/pages\/3420' data-formid='4' novalidate data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/3420\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_4_16\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-two-thirds capitalize gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_16'>\n                            \n                            <span id='input_4_16_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.3' id='input_4_16_3' value=''   aria-required='true'   placeholder='Names) *'  \/>\n                                                    <label for='input_4_16_3' class='gform-field-label gform-field-label--type-sub'>Names)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_4_16_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_16.6' id='input_4_16_6' value=''   aria-required='true'   placeholder='Surnames) *'  \/>\n                                                    <label for='input_4_16_6' class='gform-field-label gform-field-label--type-sub'>Surnames)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_4_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_66'>\n\t\t\t<li class='gchoice gchoice_4_66_0'>\n\t\t\t\t<input name='input_66' type='radio' value='Femenino' checked='checked' id='choice_4_66_0'    \/>\n\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_66_1'>\n\t\t\t\t<input name='input_66' type='radio' value='Masculino'  id='choice_4_66_1'    \/>\n\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_67\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-full gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Birthdate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_67' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_67_2_container'><label for='input_4_67_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_67[]' id='input_4_67_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_67_1_container'><label for='input_4_67_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_67[]' id='input_4_67_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_67_3_container'><label for='input_4_67_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_67[]' id='input_4_67_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you a local or international patient?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_147'>\n\t\t\t<li class='gchoice gchoice_4_147_0'>\n\t\t\t\t<input name='input_147' type='radio' value='Consulta Virtual (s\u00f3lo si resides en el extranjero)' checked='checked' id='choice_4_147_0'    \/>\n\t\t\t\t<label for='choice_4_147_0' id='label_4_147_0' class='gform-field-label gform-field-label--type-inline'>Virtual Consultation (only if you live abroad)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_147_1'>\n\t\t\t\t<input name='input_147' type='radio' value='Consulta Presencial (en consultorio)'  id='choice_4_147_1'    \/>\n\t\t\t\t<label for='choice_4_147_1' id='label_4_147_1' class='gform-field-label gform-field-label--type-inline'>In-person consultation (in office)<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_110'>Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_4_110' type='text' value='' class='large'    placeholder='Nationality *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_17\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>E-mail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_17' id='input_4_17' type='email' value='' class='large'   placeholder='Email *' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_4_68\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_68'>Mobile<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_68' id='input_4_68' type='tel' value='' class='large'  placeholder='Mobile *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_right_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_107'>ID \/ Passport<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_4_107' type='text' value='' class='large'    placeholder='ID \/ Passport *'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_23\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_country ginput_container_address gform-grid-row' id='input_4_23' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_23_1_container' >\n                                        <input type='text' name='input_23.1' id='input_4_23_1' value=''   placeholder='Street \/ Avenue \/ No.*' aria-required='true'    \/>\n                                        <label for='input_4_23_1' id='input_4_23_1_label' class='gform-field-label gform-field-label--type-sub'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_23_3_container' >\n                                    <input type='text' name='input_23.3' id='input_4_23_3' value=''   placeholder='City *' aria-required='true'    \/>\n                                    <label for='input_4_23_3' id='input_4_23_3_label' class='gform-field-label gform-field-label--type-sub'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_23_4_container' >\n                                        <input type='text' name='input_23.4' id='input_4_23_4' value=''     placeholder='State\/Province *' aria-required='true'    \/>\n                                        <label for='input_4_23_4' id='input_4_23_4_label' class='gform-field-label gform-field-label--type-sub'>State\/Province\/Region<\/label>\n                                      <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_4_23_6_container' >\n                                        <select name='input_23.6' id='input_4_23_6'   aria-required='true'    ><option value='' selected='selected'>Country *<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cape Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chili<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Curacao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >The Savior<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >sweater<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macau<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >malt<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >Meeting<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, US<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >Aland Islands<\/option><\/select>\n                                        <label for='input_4_23_6' id='input_4_23_6_label' class='gform-field-label gform-field-label--type-sub'>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_4_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_120'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_4_120' type='text' value='' class='large'    placeholder='Profession *' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_middle_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_70'>Instagram user:<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_4_70' type='text' value='' class='large'    placeholder='instagram'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_14\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gf_right_third field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_14'>Recommended by<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_4_14' type='text' value='' class='large'    placeholder='Recommended by'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_151'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_4_151' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_167\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_132\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_132'>Current Weight (lbs)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_132' id='input_4_132' type='number' step='any' min='80' max='300' value='' class='large'    placeholder='Current Weight (lbs) *' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_4_132\" \/><div class='gfield_description instruction' id='gfield_instruction_4_132'>Please enter a number from <strong>80<\/strong> to <strong>300<\/strong>.<\/div><\/div><\/li><li id=\"field_4_131\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_131'>Height (ft.,in.)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_131' id='input_4_131' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Height *<\/option><option value='60' >5 feet<\/option><option value='61' >5&#039;1<\/option><option value='62' >5&#039;2<\/option><option value='63' >5&#039;3<\/option><option value='64' >5&#039;4<\/option><option value='65' >5&#039;5<\/option><option value='66' >5&#039;6<\/option><option value='67' >5&#039;7<\/option><option value='68' >5&#039;8<\/option><option value='69' >5&#039;9<\/option><option value='70' >5&#039;10<\/option><option value='71' >5&#039;11<\/option><option value='72' >6 feet<\/option><option value='73' >6&#039;1<\/option><option value='74' >6&#039;2<\/option><option value='75' >6&#039;3<\/option><option value='76' >6&#039;4<\/option><option value='77' >6&#039;5<\/option><\/select><\/div><\/li><li id=\"field_4_152\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_152'>Blood type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_4_152' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Blood type<\/option><option value='A+' >A+<\/option><option value='A-' >TO-<\/option><option value='AB-' >AB-<\/option><option value='AB+' >AB+<\/option><option value='B+' >B+<\/option><option value='B-' >B-<\/option><option value='O-' >EITHER-<\/option><option value='O+' >O+<\/option><option value='No s\u00e9' >I don&#039;t know<\/option><\/select><\/div><\/li><li id=\"field_4_143\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter gf_left_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_143'>Height Inch<\/label><div class='ginput_container ginput_container_number'><input name='input_143' id='input_4_143' type='text' step='any' min='80' max='300' value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_133\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above hidden_label field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_133'>BMI<\/label><div class='ginput_container ginput_container_number'><input name='input_133' id='input_4_133' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='BMI'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_144\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_left_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_144'>Current Weight (kgs)<\/label><div class='ginput_container ginput_container_number'><input name='input_144' id='input_4_144' type='text' step='any' min='80' max='300' value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_142\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_right_third gfield_calculation field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_142'>Height (cm.)<\/label><div class='ginput_container ginput_container_number'><input name='input_142' id='input_4_142' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='Height (cm.)'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_4_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you suffer or have you suffered from any illnesses or health conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_153'>\n\t\t\t<li class='gchoice gchoice_4_153_0'>\n\t\t\t\t<input name='input_153' type='radio' value='S\u00ed'  id='choice_4_153_0'    \/>\n\t\t\t\t<label for='choice_4_153_0' id='label_4_153_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_153_1'>\n\t\t\t\t<input name='input_153' type='radio' value='No'  id='choice_4_153_1'    \/>\n\t\t\t\t<label for='choice_4_153_1' id='label_4_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Please specify which diseases<\/label><div class='gfield_description' id='gfield_description_4_51'>Select all that apply<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_51'><li class='gchoice gchoice_4_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Arritmias'  id='choice_4_51_1'   aria-describedby=\"gfield_description_4_51\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_1' id='label_4_51_1' class='gform-field-label gform-field-label--type-inline'>Arrhythmias<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Asma'  id='choice_4_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_2' id='label_4_51_2' class='gform-field-label gform-field-label--type-inline'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.3' type='checkbox'  value='Asma Bronquial'  id='choice_4_51_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_3' id='label_4_51_3' class='gform-field-label gform-field-label--type-inline'>Bronchial asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.4' type='checkbox'  value='Colesterol Elevado'  id='choice_4_51_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_4' id='label_4_51_4' class='gform-field-label gform-field-label--type-inline'>High cholesterol<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.5' type='checkbox'  value='Constipaci\u00f3n (estre\u00f1imiento)'  id='choice_4_51_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_5' id='label_4_51_5' class='gform-field-label gform-field-label--type-inline'>Constipation<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.6' type='checkbox'  value='Depresi\u00f3n'  id='choice_4_51_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_6' id='label_4_51_6' class='gform-field-label gform-field-label--type-inline'>Depression<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.7' type='checkbox'  value='Diabetes'  id='choice_4_51_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_7' id='label_4_51_7' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.8' type='checkbox'  value='Enfermedad Psiqui\u00e1trica'  id='choice_4_51_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_8' id='label_4_51_8' class='gform-field-label gform-field-label--type-inline'>Psychiatric Illness<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.9' type='checkbox'  value='Enfermedades del Coraz\u00f3n'  id='choice_4_51_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_9' id='label_4_51_9' class='gform-field-label gform-field-label--type-inline'>Heart disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.11' type='checkbox'  value='HIV (Sida)'  id='choice_4_51_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_11' id='label_4_51_11' class='gform-field-label gform-field-label--type-inline'>HIV (AIDS)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.12' type='checkbox'  value='Hepatitis'  id='choice_4_51_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_12' id='label_4_51_12' class='gform-field-label gform-field-label--type-inline'>Hepatitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.13' type='checkbox'  value='Hipertensi\u00f3n Arterial'  id='choice_4_51_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_13' id='label_4_51_13' class='gform-field-label gform-field-label--type-inline'>Arterial hypertension<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.14' type='checkbox'  value='Historia de anemia'  id='choice_4_51_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_14' id='label_4_51_14' class='gform-field-label gform-field-label--type-inline'>History of anemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.15' type='checkbox'  value='Infartos'  id='choice_4_51_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_15' id='label_4_51_15' class='gform-field-label gform-field-label--type-inline'>Heart attacks<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.16' type='checkbox'  value='Presi\u00f3n arterial'  id='choice_4_51_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_16' id='label_4_51_16' class='gform-field-label gform-field-label--type-inline'>Blood pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.17' type='checkbox'  value='Sangrado'  id='choice_4_51_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_17' id='label_4_51_17' class='gform-field-label gform-field-label--type-inline'>Bleeding<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.18' type='checkbox'  value='Tiroides'  id='choice_4_51_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_18' id='label_4_51_18' class='gform-field-label gform-field-label--type-inline'>Thyroid<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_19'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.19' type='checkbox'  value='Tromboflebitis'  id='choice_4_51_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_19' id='label_4_51_19' class='gform-field-label gform-field-label--type-inline'>Thrombophlebitis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_21'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.21' type='checkbox'  value='Trombosis venosa'  id='choice_4_51_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_21' id='label_4_51_21' class='gform-field-label gform-field-label--type-inline'>venous thrombosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_22'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.22' type='checkbox'  value='Varices'  id='choice_4_51_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_22' id='label_4_51_22' class='gform-field-label gform-field-label--type-inline'>Varicose veins<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_51_23'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.23' type='checkbox'  value='Otras'  id='choice_4_51_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_51_23' id='label_4_51_23' class='gform-field-label gform-field-label--type-inline'>Others<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_83'>Please specify your psychiatric condition<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_4_83' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_52'>Please specify your health problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_154\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a family history of any illness or health condition?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_154'>\n\t\t\t<li class='gchoice gchoice_4_154_0'>\n\t\t\t\t<input name='input_154' type='radio' value='S\u00ed'  id='choice_4_154_0'    \/>\n\t\t\t\t<label for='choice_4_154_0' id='label_4_154_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_154_1'>\n\t\t\t\t<input name='input_154' type='radio' value='No'  id='choice_4_154_1'    \/>\n\t\t\t\t<label for='choice_4_154_1' id='label_4_154_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_79'>Family History: Indicate if you suffer or have suffered from illnesses of close relatives (father, mother, siblings and children).<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_4_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take any medications or supplements regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_45'>(for blood pressure, antidepressants, protein, weight loss supplements, vitamins)<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_45'>\n\t\t\t<li class='gchoice gchoice_4_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='S\u00ed'  id='choice_4_45_0'    \/>\n\t\t\t\t<label for='choice_4_45_0' id='label_4_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_4_45_1'    \/>\n\t\t\t\t<label for='choice_4_45_1' id='label_4_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_33'>Specify the medications\/supplements you take<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_128\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you or a family member a carrier or suffering from FALCEMIA?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_128'>\n\t\t\t<li class='gchoice gchoice_4_128_0'>\n\t\t\t\t<input name='input_128' type='radio' value='S\u00ed'  id='choice_4_128_0'    \/>\n\t\t\t\t<label for='choice_4_128_0' id='label_4_128_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_128_1'>\n\t\t\t\t<input name='input_128' type='radio' value='No'  id='choice_4_128_1'    \/>\n\t\t\t\t<label for='choice_4_128_1' id='label_4_128_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_128_2'>\n\t\t\t\t<input name='input_128' type='radio' value='Familiar'  id='choice_4_128_2'    \/>\n\t\t\t\t<label for='choice_4_128_2' id='label_4_128_2' class='gform-field-label gform-field-label--type-inline'>Family member<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_129\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_129'>Please specify your or your family member&#039;s falcemia condition.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_4_129' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_168\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex' >Have you had any previous surgery? Select the ones that apply.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_74'><li class='gchoice gchoice_4_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Cirug\u00eda General (bari\u00e1trica, apendicectom\u00eda, extracci\u00f3n de ves\u00edcula,etc.)'  id='choice_4_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_74_1' id='label_4_74_1' class='gform-field-label gform-field-label--type-inline'>General Surgery (bariatric, appendectomy, gallbladder removal, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Cirug\u00edas Est\u00e9ticas anteriores (reducci\u00f3n de mamas, liposucci\u00f3n, etc.)'  id='choice_4_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_74_2' id='label_4_74_2' class='gform-field-label gform-field-label--type-inline'>Plastic Surgeries (breast reduction, liposuction, etc.)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_176\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-seven-twelfths gf_list_inline gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had any cosmetic or general surgery before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_176'>Example: liposuction, cesarean section, barbaric, etc.<\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_176'>\n\t\t\t<li class='gchoice gchoice_4_176_0'>\n\t\t\t\t<input name='input_176' type='radio' value='S\u00ed'  id='choice_4_176_0'    \/>\n\t\t\t\t<label for='choice_4_176_0' id='label_4_176_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_176_1'>\n\t\t\t\t<input name='input_176' type='radio' value='No'  id='choice_4_176_1'    \/>\n\t\t\t\t<label for='choice_4_176_1' id='label_4_176_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_177\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_177'>How many surgeries have you had before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_177' id='input_4_177' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_4_178\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3>Please describe the type of surgery, the date and if there were complications in each one.<\/h3><\/li><li id=\"field_4_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_87'>1st Surgery (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_4_87' type='text' value='' class='large'    placeholder='Example: Liposuction, bbl, cesarean, bariatric....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_174\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of 1st Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_174' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_174_2_container'><label for='input_4_174_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_174[]' id='input_4_174_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_174_1_container'><label for='input_4_174_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_174[]' id='input_4_174_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_174_3_container'><label for='input_4_174_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_174[]' id='input_4_174_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_180\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you have complications in the 1st surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_180'>\n\t\t\t<li class='gchoice gchoice_4_180_0'>\n\t\t\t\t<input name='input_180' type='radio' value='S\u00ed'  id='choice_4_180_0'    \/>\n\t\t\t\t<label for='choice_4_180_0' id='label_4_180_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_180_1'>\n\t\t\t\t<input name='input_180' type='radio' value='No'  id='choice_4_180_1'    \/>\n\t\t\t\t<label for='choice_4_180_1' id='label_4_180_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_184\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_184'>Specify the complications of the 1st Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_4_184' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_179\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_179'>2nd Surgery (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_4_179' type='text' value='' class='large'    placeholder='Example: Liposuction, bbl, cesarean, bariatric....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_183\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of 2nd Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_183' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_183_2_container'><label for='input_4_183_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_183[]' id='input_4_183_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_183_1_container'><label for='input_4_183_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_183[]' id='input_4_183_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_183_3_container'><label for='input_4_183_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_183[]' id='input_4_183_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_182\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you have complications in the 2nd surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_182'>\n\t\t\t<li class='gchoice gchoice_4_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='S\u00ed'  id='choice_4_182_0'    \/>\n\t\t\t\t<label for='choice_4_182_0' id='label_4_182_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='No'  id='choice_4_182_1'    \/>\n\t\t\t\t<label for='choice_4_182_1' id='label_4_182_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_181\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_181'>Specify the complications of the 2nd Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_4_181' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_185\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_185'>3rd Surgery (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_4_185' type='text' value='' class='large'    placeholder='Example: Liposuction, bbl, cesarean, bariatric....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_186\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of 3rd Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_186' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_186_2_container'><label for='input_4_186_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_186[]' id='input_4_186_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_186_1_container'><label for='input_4_186_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_186[]' id='input_4_186_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_186_3_container'><label for='input_4_186_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_186[]' id='input_4_186_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you have complications in the 3rd surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_187'>\n\t\t\t<li class='gchoice gchoice_4_187_0'>\n\t\t\t\t<input name='input_187' type='radio' value='S\u00ed'  id='choice_4_187_0'    \/>\n\t\t\t\t<label for='choice_4_187_0' id='label_4_187_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_187_1'>\n\t\t\t\t<input name='input_187' type='radio' value='No'  id='choice_4_187_1'    \/>\n\t\t\t\t<label for='choice_4_187_1' id='label_4_187_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_188\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_188'>Specify the complications of the 3rd Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_4_188' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_190\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_190'>4th Surgery (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_4_190' type='text' value='' class='large'    placeholder='Example: Liposuction, bbl, cesarean, bariatric....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_191\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of 4th Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_191' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_191_2_container'><label for='input_4_191_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_191[]' id='input_4_191_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_191_1_container'><label for='input_4_191_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_191[]' id='input_4_191_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_191_3_container'><label for='input_4_191_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_191[]' id='input_4_191_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_192\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you have complications in the 4th surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_192'>\n\t\t\t<li class='gchoice gchoice_4_192_0'>\n\t\t\t\t<input name='input_192' type='radio' value='S\u00ed'  id='choice_4_192_0'    \/>\n\t\t\t\t<label for='choice_4_192_0' id='label_4_192_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_192_1'>\n\t\t\t\t<input name='input_192' type='radio' value='No'  id='choice_4_192_1'    \/>\n\t\t\t\t<label for='choice_4_192_1' id='label_4_192_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_189\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_189'>Specify the complications of the 4th Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_4_189' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_194\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_194'>5th Surgery (type)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_4_194' type='text' value='' class='large'    placeholder='Example: Liposuction, bbl, cesarean, bariatric....' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_195\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-third fechacirugia gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of 5th Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_195' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_195_2_container'><label for='input_4_195_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_195[]' id='input_4_195_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_195_1_container'><label for='input_4_195_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_195[]' id='input_4_195_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' selected='selected'>1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_195_3_container'><label for='input_4_195_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Anno<\/label><select name='input_195[]' id='input_4_195_3'   aria-required='true'  ><option value=''>Anno<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_196\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did you have complications in the 5th surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_196'>\n\t\t\t<li class='gchoice gchoice_4_196_0'>\n\t\t\t\t<input name='input_196' type='radio' value='S\u00ed'  id='choice_4_196_0'    \/>\n\t\t\t\t<label for='choice_4_196_0' id='label_4_196_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_196_1'>\n\t\t\t\t<input name='input_196' type='radio' value='No'  id='choice_4_196_1'    \/>\n\t\t\t\t<label for='choice_4_196_1' id='label_4_196_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_193\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_193'>Specify the complications of the 5th Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_193' id='input_4_193' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_163\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' >Did you have any complications in said cosmetic surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_163'>\n\t\t\t<li class='gchoice gchoice_4_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='S\u00ed'  id='choice_4_163_0'    \/>\n\t\t\t\t<label for='choice_4_163_0' id='label_4_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='No'  id='choice_4_163_1'    \/>\n\t\t\t\t<label for='choice_4_163_1' id='label_4_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_161'>Specify about the complication you had in your previous cosmetic surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_4_161' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_93'>Previous General Surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_93'>Please specify the type of surgery(s) performed<\/div><div class='ginput_container ginput_container_text'><input name='input_93' id='input_4_93' type='text' value='' class='large'  aria-describedby=\"gfield_description_4_93\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_175\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_175'>Previous general surgery date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_175' id='input_4_175' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_175_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_175_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_175' class='gform_hidden' value='https:\/\/drmartinrobles.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_4_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' >Did you have any complications in said general surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_164'>\n\t\t\t<li class='gchoice gchoice_4_164_0'>\n\t\t\t\t<input name='input_164' type='radio' value='S\u00ed'  id='choice_4_164_0'    \/>\n\t\t\t\t<label for='choice_4_164_0' id='label_4_164_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_164_1'>\n\t\t\t\t<input name='input_164' type='radio' value='No'  id='choice_4_164_1'    \/>\n\t\t\t\t<label for='choice_4_164_1' id='label_4_164_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_162\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_162'>Specify about the complication you had in your previous general surgery<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_162' id='input_4_162' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_169\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_119\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_119'>How many pregnancies have you had?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_4_119' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Ninguno' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/li><li id=\"field_4_130\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_130'>How many children have you had?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_4_130' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Ninguno' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><\/select><\/div><\/li><li id=\"field_4_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_50'>How was your birth?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_4_50' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Parto Natural' >Natural birth<\/option><option value='Ces\u00e1rea' >Caesarean section<\/option><option value='He tenido ambos' >I have had both<\/option><\/select><\/div><\/li><li id=\"field_4_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Date of your last birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_4_73' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\"><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_4_73_2_container'><label for='input_4_73_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_73[]' id='input_4_73_2'   aria-required='true'  ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_4_73_1_container'><label for='input_4_73_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_73[]' id='input_4_73_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_4_73_3_container'><label for='input_4_73_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_73[]' id='input_4_73_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/div><\/li><li id=\"field_4_72\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you take contraceptives?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_72'>\n\t\t\t<li class='gchoice gchoice_4_72_0'>\n\t\t\t\t<input name='input_72' type='radio' value='S\u00ed'  id='choice_4_72_0'    \/>\n\t\t\t\t<label for='choice_4_72_0' id='label_4_72_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_72_1'>\n\t\t\t\t<input name='input_72' type='radio' value='No'  id='choice_4_72_1'    \/>\n\t\t\t\t<label for='choice_4_72_1' id='label_4_72_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_127\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_127'>Type of contraceptive<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_127' id='input_4_127' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='V\u00eda oral' >Orally<\/option><option value='DIU' >IUD<\/option><\/select><\/div><\/li><li id=\"field_4_36\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you allergic to any medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_36'>\n\t\t\t<li class='gchoice gchoice_4_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='S\u00ed'  id='choice_4_36_0'    \/>\n\t\t\t\t<label for='choice_4_36_0' id='label_4_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_4_36_1'    \/>\n\t\t\t\t<label for='choice_4_36_1' id='label_4_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Which medication(s) are you allergic to?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you smoke? Or did you smoke before?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_53'>\n\t\t\t<li class='gchoice gchoice_4_53_0'>\n\t\t\t\t<input name='input_53' type='radio' value='S\u00ed'  id='choice_4_53_0'    \/>\n\t\t\t\t<label for='choice_4_53_0' id='label_4_53_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_53_1'>\n\t\t\t\t<input name='input_53' type='radio' value='No'  id='choice_4_53_1'    \/>\n\t\t\t\t<label for='choice_4_53_1' id='label_4_53_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_53_2'>\n\t\t\t\t<input name='input_53' type='radio' value='Fumaba'  id='choice_4_53_2'    \/>\n\t\t\t\t<label for='choice_4_53_2' id='label_4_53_2' class='gform-field-label gform-field-label--type-inline'>used to smoke<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_156\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What do you smoke or did you smoke? Ex: cigarette, vape, etc\u2026<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_156'><li class='gchoice gchoice_4_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Cigarrillos'  id='choice_4_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_1' id='label_4_156_1' class='gform-field-label gform-field-label--type-inline'>Cigarettes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.2' type='checkbox'  value='Hooka'  id='choice_4_156_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_2' id='label_4_156_2' class='gform-field-label gform-field-label--type-inline'>Hookah<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.3' type='checkbox'  value='Vape \/ Cigarrillo Electr\u00f3nico'  id='choice_4_156_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_3' id='label_4_156_3' class='gform-field-label gform-field-label--type-inline'>Vape \/ Electronic Cigarette<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.4' type='checkbox'  value='Cigarro \/ Tabaco'  id='choice_4_156_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_4' id='label_4_156_4' class='gform-field-label gform-field-label--type-inline'>Cigar\/Tobacco<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_156_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.5' type='checkbox'  value='Marihuana'  id='choice_4_156_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_156_5' id='label_4_156_5' class='gform-field-label gform-field-label--type-inline'>Dope<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_155'>How often do you or did you smoke and how many years have you\/had you been smoking?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_4_155' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_list_inline gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Drink alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_81'>\n\t\t\t<li class='gchoice gchoice_4_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='S\u00ed'  id='choice_4_81_0'    \/>\n\t\t\t\t<label for='choice_4_81_0' id='label_4_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='No'  id='choice_4_81_1'    \/>\n\t\t\t\t<label for='choice_4_81_1' id='label_4_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_82\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_82'>How often do you drink alcohol?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_4_82' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_134\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gf_left_half gf_list_inline gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had COVID?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_4_134'>\n\t\t\t<li class='gchoice gchoice_4_134_0'>\n\t\t\t\t<input name='input_134' type='radio' value='S\u00ed'  id='choice_4_134_0'    \/>\n\t\t\t\t<label for='choice_4_134_0' id='label_4_134_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_4_134_1'>\n\t\t\t\t<input name='input_134' type='radio' value='No'  id='choice_4_134_1'    \/>\n\t\t\t\t<label for='choice_4_134_1' id='label_4_134_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_170\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_123\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gf_list_3col gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >What procedures do you want to have done?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_4_123'>To see a description of each procedure, <a href=\"https:\/\/drmartinrobles.com\/en\/procedimientos\/\" target=\"_blank\">enter here<\/a>.<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_4_123'><li class='gchoice gchoice_4_123_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.1' type='checkbox'  value='Abdominoplast\u00eda'  id='choice_4_123_1'   aria-describedby=\"gfield_description_4_123\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_1' id='label_4_123_1' class='gform-field-label gform-field-label--type-inline'>Abdominoplasty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.2' type='checkbox'  value='BBL - Injerto de Grasa en Gl\u00fateos'  id='choice_4_123_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_2' id='label_4_123_2' class='gform-field-label gform-field-label--type-inline'>BBL \u2013 Gluteal Fat Graft<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.3' type='checkbox'  value='Braquioplast\u00eda'  id='choice_4_123_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_3' id='label_4_123_3' class='gform-field-label gform-field-label--type-inline'>Brachioplasty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.4' type='checkbox'  value='Cruroplast\u00eda'  id='choice_4_123_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_4' id='label_4_123_4' class='gform-field-label gform-field-label--type-inline'>Cruroplasty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.5' type='checkbox'  value='Injerto de Grasa a Mamas'  id='choice_4_123_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_5' id='label_4_123_5' class='gform-field-label gform-field-label--type-inline'>Breast Fat Graft<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.6' type='checkbox'  value='J-Plasma'  id='choice_4_123_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_6' id='label_4_123_6' class='gform-field-label gform-field-label--type-inline'>J-Plasma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.7' type='checkbox'  value='Lifting Facial'  id='choice_4_123_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_7' id='label_4_123_7' class='gform-field-label gform-field-label--type-inline'>Facial Lift<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.8' type='checkbox'  value='Lipo Papada'  id='choice_4_123_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_8' id='label_4_123_8' class='gform-field-label gform-field-label--type-inline'>Double Chin Lipo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.9' type='checkbox'  value='Lipo Vaser'  id='choice_4_123_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_9' id='label_4_123_9' class='gform-field-label gform-field-label--type-inline'>Lipo Vaser<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.11' type='checkbox'  value='Lipo de Brazos'  id='choice_4_123_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_11' id='label_4_123_11' class='gform-field-label gform-field-label--type-inline'>Arm Liposuction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.12' type='checkbox'  value='Lipoescultura'  id='choice_4_123_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_12' id='label_4_123_12' class='gform-field-label gform-field-label--type-inline'>Liposculture<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.13' type='checkbox'  value='Mamoplast\u00eda de Aumento'  id='choice_4_123_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_13' id='label_4_123_13' class='gform-field-label gform-field-label--type-inline'>Augmentation Mammoplasty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.14' type='checkbox'  value='Marcaci\u00f3n Abdominal'  id='choice_4_123_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_14' id='label_4_123_14' class='gform-field-label gform-field-label--type-inline'>Abdominal Marking<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.15' type='checkbox'  value='Mastopexia con Implantes'  id='choice_4_123_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_15' id='label_4_123_15' class='gform-field-label gform-field-label--type-inline'>Mammoplasty with Implants<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.16' type='checkbox'  value='Mini Abdominoplast\u00eda'  id='choice_4_123_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_16' id='label_4_123_16' class='gform-field-label gform-field-label--type-inline'>Mini Abdominoplasty<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.17' type='checkbox'  value='Reducci\u00f3n Mamaria'  id='choice_4_123_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_17' id='label_4_123_17' class='gform-field-label gform-field-label--type-inline'>Breast Reduction<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_4_123_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_123.18' type='checkbox'  value='Otros'  id='choice_4_123_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_123_18' id='label_4_123_18' class='gform-field-label gform-field-label--type-inline'>Others<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_4_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_125'>Another procedure of interest<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_4_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_4_171\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_150\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><span style=\"color: #ffffff; font-size:22px;line-height:28px;font-weight:400;\">Please send us 5 photos in the following positions: standing frontally, standing sideways, standing back, sitting front, sitting sideways, and face if applicable for your procedure.<br \/><br \/>\nNote: without underwear or small underwear. Without showing your face.<\/span>\n<\/li><li id=\"field_4_112\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_left_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_112'>Front Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_112' id='input_4_112' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_112\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_112'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_112'><\/div> <\/div><\/li><li id=\"field_4_115\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_middle_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_115'>Side Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_115' id='input_4_115' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_115\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_115'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_115'><\/div> <\/div><\/li><li id=\"field_4_114\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_right_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_114'>Back Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_114' id='input_4_114' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_114\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_114'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_114'><\/div> <\/div><\/li><li id=\"field_4_113\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_left_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_113'>Front Sitting Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_113' id='input_4_113' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_113\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_113'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_113'><\/div> <\/div><\/li><li id=\"field_4_117\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_middle_third file_upload gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_117'>Side Sitting Photo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_117' id='input_4_117' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_117\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_117'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_117'><\/div> <\/div><\/li><li id=\"field_4_116\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-half gf_right_third file_upload field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_116'>Additional Photo<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='10485760' \/><input name='input_116' id='input_4_116' type='file' class='medium' aria-describedby=\"gfield_upload_rules_4_116\" onchange='javascript:gformValidateFileSize( this, 10485760 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_116'>Accepted file types: jpg, png, jpeg, Max. file size: 10 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_4_116'><\/div> <\/div><\/li><li id=\"field_4_172\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_4_145\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_145'>When would you like to have this surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_145' id='input_4_145' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Inmediatamente' >Immediately<\/option><option value='Lo antes posible' >As soon as possible<\/option><option value='Pr\u00f3ximos meses' >Next months<\/option><option value='Este a\u00f1o' >This year<\/option><option value='El a\u00f1o entrante' >Next year<\/option><option value='Depende' >Depends<\/option><\/select><\/div><\/li><li id=\"field_4_160\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_160'>Preferred Language<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_160' id='input_4_160' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Espa\u00f1ol' >Spanish<\/option><option value='Ingl\u00e9s' >English<\/option><\/select><\/div><\/li><li id=\"field_4_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_13'>Comment:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_4_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_4_105\" class=\"gfield gfield--type-select gfield--input-type-select gf_right_half field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_4_105'>Lead Source<\/label><div class='ginput_container ginput_container_select'><select name='input_105' id='input_4_105' class='medium gfield_select'     aria-invalid=\"false\" ><option value='P\u00e1gina Web' selected='selected'>Web page<\/option><\/select><\/div><\/li><li id=\"field_4_101\" class=\"gfield gfield--type-section gfield--input-type-section gsection pdf_no_display field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><h2 class=\"gsection_title\">Consent<\/h2><div class='gsection_description' id='gfield_description_4_101'><h4>Please read the terms carefully<\/h4>\n<p style=\"font-size:12px; line-height:22px;\">I, {Name (First Name):16.3} {First Name (Surname):16.6}, bearer of the identity and electoral card and\/or passport No. {Cedula Number:107}{Passport Number:108} , of nationality {Nationality:110}, on the day {date_dmy}. I DECLARE UNDER FAITH OATH, I am the only one responsible for any damage caused to me by any omission to the bad information that I have provided in this document after having carefully read the questions asked by Doctor Martin Robles, and I understand that hiding any type of medical information from this or its medical staff could put my life and health at risk, as well as my obligation to notify any change or alteration to the information provided here.\n<br \/><br \/>\nPatient&#039;s signature<br \/><br \/><br \/>\n\n\n ______________________________<br \/>\n {First Name (First Name):16.3} {First Name (Last Name):16.6}<\/p><\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Send'  \/> <input type='hidden' name='gform_ajax' 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