{"id":1167,"date":"2022-07-12T08:09:46","date_gmt":"2022-07-12T08:09:46","guid":{"rendered":"https:\/\/rwjmyhealthkiosk.gomohealth.care\/enrollment\/"},"modified":"2024-06-27T12:19:50","modified_gmt":"2024-06-27T12:19:50","slug":"enroll","status":"publish","type":"page","link":"https:\/\/rwjmyhealthkiosk.gomohealth.care\/es\/enroll\/","title":{"rendered":"Enrollment"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1064.96px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_16' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_16'  action='\/es\/wp-json\/wp\/v2\/pages\/1167' >\n                        <div class='gform_body gform-body'><ul id='gform_fields_16' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_16_20\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_20\"><div class='ginput_container ginput_container_text'><input name='input_20' id='input_16_20' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_16_1\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_1\"><div class='ginput_container ginput_container_text'><input name='input_1' id='input_16_1' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_16_2\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_2\"><div class='ginput_container ginput_container_text'><input name='input_2' id='input_16_2' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_16_3\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_3\"><div class='ginput_container ginput_container_text'><input name='input_3' id='input_16_3' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/rwjmyhealthkiosk.gomohealth.care\/es\/wp-json\/wp\/v2\/pages\/1167' \/><\/div><\/li><li id=\"field_16_4\"  class=\"gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_4\"><div class='ginput_container ginput_container_text'><input name='input_4' id='input_16_4' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/li><li id=\"field_16_24\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_24\"><span style=\"font-style: italic;\">Un <span style=\"font-weight: bold; color: rgba(166,66,66,1);\">*<\/span> indica un campo obligatorio.<\/span><\/li><li id=\"field_16_25\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_25\"><label class='gfield_label'  >\u00bfQu\u00e9 idioma prefiere?<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_16_25'>\n\t\t\t<li class='gchoice gchoice_16_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='English'  id='choice_16_25_0'    \/>\n\t\t\t\t<label for='choice_16_25_0' id='label_16_25_0'>Ingles<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Spanish'  id='choice_16_25_1'    \/>\n\t\t\t\t<label for='choice_16_25_1' id='label_16_25_1'>Espa\u00f1ol<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='Mandarin Chinese'  id='choice_16_25_2'    \/>\n\t\t\t\t<label for='choice_16_25_2' id='label_16_25_2'>Chino mandar\u00edn<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_3'>\n\t\t\t\t<input name='input_25' type='radio' value='Hindi'  id='choice_16_25_3'    \/>\n\t\t\t\t<label for='choice_16_25_3' id='label_16_25_3'>Hindi<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_4'>\n\t\t\t\t<input name='input_25' type='radio' value='Russian'  id='choice_16_25_4'    \/>\n\t\t\t\t<label for='choice_16_25_4' id='label_16_25_4'>Ruso<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_5'>\n\t\t\t\t<input name='input_25' type='radio' value='Arabic'  id='choice_16_25_5'    \/>\n\t\t\t\t<label for='choice_16_25_5' id='label_16_25_5'>\u00c1rabe<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_25_6'>\n\t\t\t\t<input name='input_25' type='radio' value='Other'  id='choice_16_25_6'    \/>\n\t\t\t\t<label for='choice_16_25_6' id='label_16_25_6'>Otro<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_39\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_39\"><p style=\"font-weight: 700;\">Esta plataforma no es compatible con el idioma que eligi\u00f3 en este momento, pero tenemos navegadores que hablan su idioma y, por lo tanto, pueden proporcionar servicios de chat personalizados.<\/p><\/li><li id=\"field_16_40\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_40\"><p style=\"font-weight: 700;\">Esta plataforma no es compatible con el idioma que eligi\u00f3 en este momento, pero tenemos navegadores que hablan su idioma y, por lo tanto, pueden proporcionar servicios de chat personalizados.<\/p><\/li><li id=\"field_16_37\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_37\"><label class='gfield_label' for='input_16_37' >Si seleccion\u00f3 \u201cOtro\u201d, ind\u00edquelo aqu\u00ed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_16_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_16_6\"  class=\"gfield gfield_contains_required field_sublabel_above field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_6\"><label class='gfield_label gfield_label_before_complex'  >Nombre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_16_6'>\n                            \n                            <span id='input_16_6_3_container' class='name_first' >\n                                                    <label for='input_16_6_3' >Primer nombre:<\/label>\n                                                    <input type='text' name='input_6.3' id='input_16_6_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_16_6_6_container' class='name_last' >\n                                                            <label for='input_16_6_6' >Apellido:<\/label>\n                                                            <input type='text' name='input_6.6' id='input_16_6_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/li><li id=\"field_16_7\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_7\"><label class='gfield_label' for='input_16_7' >N\u00famero de tel\u00e9fono m\u00f3vil:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_16_7' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_16_21\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_21\"><label class='gfield_label' for='input_16_21' >Fecha de nacimiento:<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_21' id='input_16_21' type='text' value='' class='datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_16_21_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_16_21_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_16_21' class='gform_hidden' value='\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_16_22\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_22\"><label class='gfield_label' for='input_16_22' >Correo electr\u00f3nico:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_22' id='input_16_22' type='text' value='' class='medium'     aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_16_38\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_38\"><label class='gfield_label' for='input_16_38' >C\u00f3digo postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_16_38' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_16_13\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_16_13\"><label class='gfield_label gfield_label_before_complex'  >Raza\/Origen \u00e9tnico:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_16_13'>Seleccione todas las opciones que correspondan<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_13'><li class='gchoice gchoice_16_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='American Indian\/Alaska Native'  id='choice_16_13_1'   aria-describedby=\"gfield_description_16_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_1' id='label_16_13_1'>Indio americano\/Nativo de Alaska<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.2' type='checkbox'  value='Asian'  id='choice_16_13_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_2' id='label_16_13_2'>Asi\u00e1tico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.3' type='checkbox'  value='Black\/African American'  id='choice_16_13_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_3' id='label_16_13_3'>Negro\/Afroamericano<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.4' type='checkbox'  value='Caucasian\/White'  id='choice_16_13_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_4' id='label_16_13_4'>Cauc\u00e1sico\/Blanco<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.5' type='checkbox'  value='Hispanic\/Latino'  id='choice_16_13_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_5' id='label_16_13_5'>Hispano\/Latino<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.6' type='checkbox'  value='Native Hawaiian\/Pacific Islander'  id='choice_16_13_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_6' id='label_16_13_6'>Nativo de Haw\u00e1i\/Isle\u00f1o del Pac\u00edfico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.7' type='checkbox'  value='Southeast Asian'  id='choice_16_13_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_7' id='label_16_13_7'>Del Sudeste Asi\u00e1tico<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_13_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.8' type='checkbox'  value='Choose not to answer'  id='choice_16_13_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_13_8' id='label_16_13_8'>Prefiere no responder<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_26\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_26\"><label class='gfield_label'  >\u00bfCu\u00e1l fue su sexo biol\u00f3gico al nacer?<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_16_26'>\n\t\t\t<li class='gchoice gchoice_16_26_0'>\n\t\t\t\t<input name='input_26' type='radio' value='Male'  id='choice_16_26_0'    \/>\n\t\t\t\t<label for='choice_16_26_0' id='label_16_26_0'>Hombre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_26_1'>\n\t\t\t\t<input name='input_26' type='radio' value='Female'  id='choice_16_26_1'    \/>\n\t\t\t\t<label for='choice_16_26_1' id='label_16_26_1'>Mujer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_26_2'>\n\t\t\t\t<input name='input_26' type='radio' value='Choose not to answer'  id='choice_16_26_2'    \/>\n\t\t\t\t<label for='choice_16_26_2' id='label_16_26_2'>Prefiere no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_27\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_27\"><label class='gfield_label'  >\u00bfCon que g\u00e9nero se identifica?<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_16_27'>\n\t\t\t<li class='gchoice gchoice_16_27_0'>\n\t\t\t\t<input name='input_27' type='radio' value='Male'  id='choice_16_27_0'    \/>\n\t\t\t\t<label for='choice_16_27_0' id='label_16_27_0'>Hombre<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_27_1'>\n\t\t\t\t<input name='input_27' type='radio' value='Female'  id='choice_16_27_1'    \/>\n\t\t\t\t<label for='choice_16_27_1' id='label_16_27_1'>Mujer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_27_2'>\n\t\t\t\t<input name='input_27' type='radio' value='Binary'  id='choice_16_27_2'    \/>\n\t\t\t\t<label for='choice_16_27_2' id='label_16_27_2'>Binario<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_27_3'>\n\t\t\t\t<input name='input_27' type='radio' value='Transgender (male to female)'  id='choice_16_27_3'    \/>\n\t\t\t\t<label for='choice_16_27_3' id='label_16_27_3'>Transg\u00e9nero (hombre a mujer)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_27_4'>\n\t\t\t\t<input name='input_27' type='radio' value='Transgender (female to male)'  id='choice_16_27_4'    \/>\n\t\t\t\t<label for='choice_16_27_4' id='label_16_27_4'>Transg\u00e9nero (mujer a hombre)<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_27_5'>\n\t\t\t\t<input name='input_27' type='radio' value='Choose not to answer'  id='choice_16_27_5'    \/>\n\t\t\t\t<label for='choice_16_27_5' id='label_16_27_5'>Prefiere no responder<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_28\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_28\"><label class='gfield_label'  >\u00bfTiene un tel\u00e9fono celular para uso personal?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_28'>\n\t\t\t<li class='gchoice gchoice_16_28_0'>\n\t\t\t\t<input name='input_28' type='radio' value='Yes'  id='choice_16_28_0'    \/>\n\t\t\t\t<label for='choice_16_28_0' id='label_16_28_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_28_1'>\n\t\t\t\t<input name='input_28' type='radio' value='No'  id='choice_16_28_1'    \/>\n\t\t\t\t<label for='choice_16_28_1' id='label_16_28_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_29\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_29\"><label class='gfield_label'  >\u00bfFuma tabaco actualmente o ha fumado tabaco en el pasado?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_16_29'>\n\t\t\t<li class='gchoice gchoice_16_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='I have never smoked'  id='choice_16_29_0'    \/>\n\t\t\t\t<label for='choice_16_29_0' id='label_16_29_0'>Nunca he fumado<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='I currently smoke'  id='choice_16_29_1'    \/>\n\t\t\t\t<label for='choice_16_29_1' id='label_16_29_1'>Actualmente fumo<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_29_2'>\n\t\t\t\t<input name='input_29' type='radio' value='I previously smoked'  id='choice_16_29_2'    \/>\n\t\t\t\t<label for='choice_16_29_2' id='label_16_29_2'>Antes fumaba<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_30\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_30\"><label class='gfield_label' for='input_16_30' >\u00bfCu\u00e1ntos a\u00f1os fum\u00f3?<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_16_30' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Por favor selecciona -<\/option><option value='0-5 years' >0-5 a\u00f1os<\/option><option value='6-10 years' >6-10 a\u00f1os<\/option><option value='11-15 years' >11-15 a\u00f1os<\/option><option value='16-20+ years' >16-20+ a\u00f1os<\/option><\/select><\/div><\/li><li id=\"field_16_31\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_31\"><label class='gfield_label' for='input_16_31' >\u00bfCu\u00e1ntos paquetes al d\u00eda fuma?<\/label><div class='ginput_container ginput_container_select'><select name='input_31' id='input_16_31' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Por favor selecciona -<\/option><option value='0-5 packs a day' >0-5 paquetes al d\u00eda<\/option><option value='6-10 packs a day' >6-10 paquetes al d\u00eda<\/option><option value='11-15 packs a day' >11-15 paquetes al d\u00eda<\/option><option value='16-20+ packs a day' >16-20+ paquetes al d\u00eda<\/option><\/select><\/div><\/li><li id=\"field_16_32\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_32\"><label class='gfield_label' for='input_16_32' >\u00bfHace cu\u00e1ntos a\u00f1os dej\u00f3 de fumar?<\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_16_32' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Por favor selecciona -<\/option><option value='0-5 years' >0-5 a\u00f1os<\/option><option value='6-10 years' >6-10 a\u00f1os<\/option><option value='11-15 years' >11-15 a\u00f1os<\/option><option value='16-20+ years' >16-20+ a\u00f1os<\/option><\/select><\/div><\/li><li id=\"field_16_33\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_33\"><label class='gfield_label' for='input_16_33' >\u00bfCu\u00e1ntos a\u00f1os fum\u00f3?<\/label><div class='ginput_container ginput_container_select'><select name='input_33' id='input_16_33' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Por favor selecciona -<\/option><option value='0-5 years' >0-5 a\u00f1os<\/option><option value='6-10 years' >6-10 a\u00f1os<\/option><option value='11-15 years' >11-15 a\u00f1os<\/option><option value='16-20+ years' >16-20+ a\u00f1os<\/option><\/select><\/div><\/li><li id=\"field_16_34\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_34\"><label class='gfield_label' for='input_16_34' >\u00bfCu\u00e1ntos paquetes al d\u00eda fuma?<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_16_34' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Por favor selecciona -<\/option><option value='0-5 packs a day' >0-5 paquetes al d\u00eda<\/option><option value='6-10 packs a day' >6-10 paquetes al d\u00eda<\/option><option value='11-15 packs a day' >11-15 paquetes al d\u00eda<\/option><option value='16-20+ packs a day' >16-20+ paquetes al d\u00eda<\/option><\/select><\/div><\/li><li id=\"field_16_36\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_36\"><label class='gfield_label'  >\u00bfAlguno de sus familiares ha sido diagnosticado alguna vez con c\u00e1ncer?<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_16_36'>\n\t\t\t<li class='gchoice gchoice_16_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_16_36_0'    \/>\n\t\t\t\t<label for='choice_16_36_0' id='label_16_36_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_16_36_1'    \/>\n\t\t\t\t<label for='choice_16_36_1' id='label_16_36_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_44\"  class=\"gfield gfield--width-full special-checkbox gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible\"  data-js-reload=\"field_16_44\"><label class='gfield_label gfield_label_before_complex'  >\u00bfQu\u00e9 tipo de mensajes te gustar\u00eda recibir?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_16_44'>Seleccione todas las opciones que correspondan<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_16_44'><li class='gchoice gchoice_16_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Cancer'  id='choice_16_44_1'   aria-describedby=\"gfield_description_16_44\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_1' id='label_16_44_1'>C\u00e1ncer<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Long Covid'  id='choice_16_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_2' id='label_16_44_2'>Covid largo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Asthma'  id='choice_16_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_3' id='label_16_44_3'>Asma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='None'  id='choice_16_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_4' id='label_16_44_4'>Ninguno<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_44_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.5' type='checkbox'  value='All'  id='choice_16_44_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_5' id='label_16_44_5'>Todo<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_16_44_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.6' type='checkbox'  value='Other'  id='choice_16_44_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_16_44_6' id='label_16_44_6'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_45\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_45\"><label class='gfield_label' for='input_16_45' >Usted eligi\u00f3 &quot;Otro&quot;, por favor especifique:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_16_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_16_42\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_42\"><label class='gfield_label'  >\u00bfHay algo espec\u00edficamente en lo que podamos ayudarte?<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_16_42'>\n\t\t\t<li class='gchoice gchoice_16_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_16_42_0'    \/>\n\t\t\t\t<label for='choice_16_42_0' id='label_16_42_0'>S\u00ed<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_16_42_1'    \/>\n\t\t\t\t<label for='choice_16_42_1' id='label_16_42_1'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_16_42_2'>\n\t\t\t\t<input name='input_42' type='radio' value='Not at this time'  id='choice_16_42_2'    \/>\n\t\t\t\t<label for='choice_16_42_2' id='label_16_42_2'>No en este momento<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_16_43\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_43\"><label class='gfield_label' for='input_16_43' >Por favor explique<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_43' id='input_16_43' class='textarea small'   maxlength='250'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_16_41\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_16_41\"><label class='gfield_label gfield_label_before_complex'  >Consentir<span class=\"gfield_required\"><span class=\"gfield_required 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