{"id":3781,"date":"2020-09-28T21:11:48","date_gmt":"2020-09-29T02:11:48","guid":{"rendered":"http:\/\/www.childrenscvm.com\/patient-registration-form\/"},"modified":"2021-03-30T12:32:05","modified_gmt":"2021-03-30T17:32:05","slug":"registro-de-pacientes-form","status":"publish","type":"page","link":"https:\/\/www.childrenscvm.com\/es\/registro-de-pacientes-form\/","title":{"rendered":"Formulario de registro del Paciente"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3781\" class=\"elementor elementor-3781 elementor-3314\" data-elementor-settings=\"[]\">\n\t\t\t\t\t\t<div class=\"elementor-inner\">\n\t\t\t\t\t\t\t<div class=\"elementor-section-wrap\">\n\t\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ee9db51 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ee9db51\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t\t\t<div class=\"elementor-row\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-75a3115\" data-id=\"75a3115\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-column-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-224fbf7 elementor-widget elementor-widget-shortcode\" data-id=\"224fbf7\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f4875-o1\" lang=\"es-ES\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/3781#wpcf7-f4875-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4875\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.4.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4875-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"form-row\">\n<div class=\"col-12\">\n<h5>INFORMACION DEL PACIENTE<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Apellido<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap apellido\"><input type=\"text\" name=\"apellido\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellido\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Nombre<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombre\"><input type=\"text\" name=\"nombre\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"fechanacimiento\">Fecha de Nacimiento<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechanacimiento\"><input type=\"date\" name=\"fechanacimiento\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha Nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Gen\u00e9ro<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap Genero\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><span class=\"wpcf7-list-item-label\">Ni\u00f1o<\/span><input type=\"checkbox\" name=\"Genero[]\" value=\"Ni\u00f1o\" \/><\/span><span class=\"wpcf7-list-item last\"><span class=\"wpcf7-list-item-label\">Ni\u00f1a<\/span><input type=\"checkbox\" name=\"Genero[]\" value=\"Ni\u00f1a\" \/><\/span><\/span><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Direcci\u00f3n<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap direccion\"><input type=\"text\" name=\"direccion\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Ciudad<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap ciudad\"><input type=\"text\" name=\"ciudad\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Estado<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap estado\"><input type=\"text\" name=\"estado\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">C\u00f3digo postal<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap codigopostal\"><input type=\"text\" name=\"codigopostal\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"C\u00f3digo postal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefono\"><input type=\"number\" name=\"telefono\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Celular<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap celular\"><input type=\"number\" name=\"celular\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Celular\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-12\">\n    <label for=\"inputPassword4\">\u00bfTiene el paciente alguna alergia?<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap Tieneelpacientealgunaalergia\"><textarea name=\"Tieneelpacientealgunaalergia\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfTiene el paciente alguna alergia?\"><\/textarea><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>M\u00c9DICO PRIMARIO O PEDIATRA<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del m\u00e9dico primario:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreMedico\"><input type=\"text\" name=\"nombreMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del m\u00e9dico primario\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefonoMedico\"><input type=\"number\" name=\"telefonoMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fax:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap faxMedico\"><input type=\"number\" name=\"faxMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fax\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>INFORMACION DE LA FARMACIA<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre de la farmacia:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreFarmacia\"><input type=\"text\" name=\"nombreFarmacia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre de la farmacia\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefonoFarmacia\"><input type=\"number\" name=\"telefonoFarmacia\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fax:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap faxFarmacia\"><input type=\"number\" name=\"faxFarmacia\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fax\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>INFORMACION DE QUIEN TIENE CUSTODIA LEGAL.(Padres o Custodio Legal)<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreCustodia\"><input type=\"text\" name=\"nombreCustodia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Apellido:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreCustodia\"><input type=\"text\" name=\"nombreCustodia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellido\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fecha Nacimiento:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechanacimientoCustodia\"><input type=\"date\" name=\"fechanacimientoCustodia\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha Nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">N\u00famero de Seguro social:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap numeroCustodia\"><input type=\"number\" name=\"numeroCustodia\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero de Seguro social\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Direcci\u00f3n de correo electr\u00f3nico:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap correoCustodia\"><input type=\"email\" name=\"correoCustodia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n de correo electr\u00f3nico\" \/><\/span><\/p>\n<div class=\"w-100\">\n<h6>(Tenga en cuenta que la persona que tenga la custodia legal del paciente; si no son los padres, deber\u00e1<br \/>\npresentar los documentos necesarios al momento de la cita.)<\/h6>\n<\/div>\n<\/div>\n<div class=\"col-12\">\n<h5>CONTACTO DE EMERGENCIA<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre completo:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreEmergencia\"><input type=\"text\" name=\"nombreEmergencia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre completo\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefonoEmergencia\"><input type=\"number\" name=\"telefonoEmergencia\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Relaci\u00f3n con el paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap relacionEmergencia\"><input type=\"text\" name=\"relacionEmergencia\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relaci\u00f3n con el paciente\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>INFORMACION DE QUIEN ES RESPONSABLE DEL PAGO<\/h5>\n<h6>Relaci\u00f3n con el paciente. Marque el que corresponda:<\/h6>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Madre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap madrePago\"><input type=\"text\" name=\"madrePago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Madre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n    <label for=\"inputEmail4\">Padre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap padrePago\"><input type=\"text\" name=\"padrePago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Padre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Custodio legal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap custodioPago\"><input type=\"text\" name=\"custodioPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Custodio legal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Otro:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap otroPago\"><input type=\"text\" name=\"otroPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Otro\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Apellido:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap apellidoPago\"><input type=\"text\" name=\"apellidoPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellido\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombrePago\"><input type=\"text\" name=\"nombrePago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fecha Nacimiento:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechanacimientoPago\"><input type=\"date\" name=\"fechanacimientoPago\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha Nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">N\u00famero Seguro Social:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap numeroPago\"><input type=\"number\" name=\"numeroPago\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero Seguro Social\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Direcci\u00f3n de residencia:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap dirPago\"><input type=\"text\" name=\"dirPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n de residencia\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Ciudad:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap ciudadPago\"><input type=\"text\" name=\"ciudadPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ciudad\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Estado:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap estadoPago\"><input type=\"text\" name=\"estadoPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">C\u00f3digo postal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap codigoPago\"><input type=\"number\" name=\"codigoPago\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"C\u00f3digo postal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefonoPago\"><input type=\"number\" name=\"telefonoPago\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Tel\u00e9fono de oficina::<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telOficinaPago\"><input type=\"number\" name=\"telOficinaPago\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono de oficina:\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Direcci\u00f3n de correo electr\u00f3nico:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap correoPago\"><input type=\"email\" name=\"correoPago\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n de correo electr\u00f3nico\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>INFORMACION DEL SEGURO M\u00c9DICO<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del Seguro M\u00e9dico (a seguranza):<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreSeguroMedico\"><input type=\"text\" name=\"nombreSeguroMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del Seguro M\u00e9dico (a seguranza)\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n    <label for=\"inputEmail4\">Apellido del asegurado principal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap apellidoMedico\"><input type=\"text\" name=\"apellidoMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Apellido del asegurado principal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreMedico\"><input type=\"text\" name=\"nombreMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fecha Nacimiento:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechaMedico\"><input type=\"date\" name=\"fechaMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha Nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">N\u00famero de P\u00f3liza:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap numeroPolizaMedico\"><input type=\"number\" name=\"numeroPolizaMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero de P\u00f3liza\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Direcci\u00f3n:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap dirMedico\"><input type=\"text\" name=\"dirMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Estado:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap estadoMedico\"><input type=\"text\" name=\"estadoMedico\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estado\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">C\u00f3digo Postal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap codigoMedico\"><input type=\"number\" name=\"codigoMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"C\u00f3digo Postal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telMedico\"><input type=\"number\" name=\"telMedico\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>SI EL PACIENTE ES RECIEN NACIDO<\/h5>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">\u00bf\u00c9l bebe tiene seguro m\u00e9dico? nombre::<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap lbebetieneseguromdico\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"lbebetieneseguromdico[]\" value=\"Si\" \/><span class=\"wpcf7-list-item-label\">Si<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"lbebetieneseguromdico[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n    <\/div>\n<div class=\"form-group col-12\">\n<h6>Yo, autorizo cualquier tratamiento o procedimiento m\u00e9dico, que sea necesario para el cuidado<br \/>\n    m\u00e9dico de mi hijo\/a que sea requerido por el profesional de la salud de Children\u2019s<br \/>\n    Cardiovascular Medicine &amp; Family Preventive Medicine.<\/h6>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreRecien\"><input type=\"text\" name=\"nombreRecien\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Firma del custodio legal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap firmaRecien\"><input type=\"text\" name=\"firmaRecien\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Firma del custodio legal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputPassword4\">Fecha:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechaRecien\"><input type=\"date\" name=\"fechaRecien\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-12\">\n<h6>Pol\u00edticas de Financiamiento<br\/><br \/>\n        Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine<\/h6>\n<h6>Seguro M\u00e9dico (aseguranza)<\/h6>\n<p>Aceptamos casi todos los seguros m\u00e9dicos, si el paciente no tiene seguro m\u00e9dico el pago total es requerido en el momento de la visita. Nosotros mandaremos al departamento de cobro de su seguro m\u00e9dico el costo de la visita. Por favor recuerde que algunas veces su seguro m\u00e9dico requiere de cierta informaci\u00f3n directamente de usted con el fin de procesar su cobro. Por favor d\u00e9jenos saber si hace alg\u00fan cambio de seguro m\u00e9dico Usted podr\u00eda ser responsable del pago si la informaci\u00f3n sobre su seguro m\u00e9dico no es reportada a tiempo.<\/p>\n<p>Todos los saldos no pagados por la compa\u00f1\u00eda de seguros dentro de <strong>60<\/strong> d\u00edas de la fecha de<br \/>\n        notificaci\u00f3n ser\u00e1n de su responsabilidad.<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <span class=\"wpcf7-form-control-wrap inicialesAPolitica\"><input type=\"text\" name=\"inicialesAPolitica\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n        <label for=\"inputEmail4\">Por favor ponga sus iniciales aceptando que ley\u00f3 y est\u00e1 de acuerdo.<\/label>\n    <\/div>\n<div class=\"form-group col-12\">\n<h6>Co-pagos y Deducibles<\/h6>\n<p>Todos los co-pagos y deducibles deber\u00e1n ser efectuados al momento de la visita. Los pagos de balances pasados deber\u00e1n ser cancelados en su totalidad en el momento de la visita. Todos los cheques que se devuelvan por fondos insuficientes o cancelaci\u00f3n de la cuenta, tendr\u00e1n un cargo de $25. Por favor tenga en cuenta que, si el balance de su cuenta tiene m\u00e1s de 90 d\u00edas de mora, nosotros mandaremos la cuenta a una agencia de colecci\u00f3n<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <span class=\"wpcf7-form-control-wrap inicialesCoPagos\"><input type=\"text\" name=\"inicialesCoPagos\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n        <label for=\"inputEmail4\">Por favor ponga sus iniciales aceptando que ley\u00f3 y est\u00e1 de acuerdo.<\/label>\n    <\/div>\n<div class=\"form-group col-12\">\n<h6>Cancelaci\u00f3n de Citas<\/h6>\n<p>Son las reglas de esta oficina cobrar por la inasistencia de citas, ya que es un espacio que puede ser utilizado para otro paciente. Entendemos que la inasistencia de citas puede ocurrir debido a una emergencia. Le pedimos que nos d\u00e9jenos saber con 24 horas de anticipaci\u00f3n si usted no puede asistir para poder agendarle una nueva cita.<\/p>\n<p>Padre o\/ Guardi\u00e1n legal.<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <span class=\"wpcf7-form-control-wrap inicialesCancelacion\"><input type=\"text\" name=\"inicialesCancelacion\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><br \/>\n        <label for=\"inputEmail4\">Por favor ponga sus iniciales aceptando que ley\u00f3 y est\u00e1 de acuerdo.<\/label>\n    <\/div>\n<div class=\"form-group col-12\">\n<p>Entendemos que hay situaciones financieras que pueden impedirle el pago a tiempo de su cuenta, si usted necesito m\u00e1s tiempo por favor llame a el departamento de cobranzas para llegar a un arreglo.<\/p>\n<p>Queremos brindarle el mejor servicio. D\u00e9jenos saber cualquier inquietud que tenga, para poder<br \/>\nayudarlo.<\/p>\n<p>Para el pago de deducibles y porcentajes de responsabilidad del paciente, la oficina le facilitara un plan de pagos si fuera necesario.<\/p>\n<p>Yo, autorizo a Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine, para que d\u00e9 a el seguro m\u00e9dico la informaci\u00f3n necesaria para el pago de los servicios prestados.<\/p>\n<p>He le\u00eddo y entiendo las normas financieras de esta oficina.<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del Custodio legal (Escrito):<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreEscritorio\"><input type=\"text\" name=\"nombreEscritorio\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del Custodio legal (Escrito)\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombrePacienteEscritorio\"><input type=\"text\" name=\"nombrePacienteEscritorio\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Firma del custodio legal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap firmaEscritorio\"><input type=\"text\" name=\"firmaEscritorio\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Firma del custodio legal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Fecha:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechaPacienteEscritorio\"><input type=\"date\" name=\"fechaPacienteEscritorio\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>AUTORIZACION DEL PACIENTE PARA USAR Y REVELAR<br\/><br \/>\n        INFORMACION M\u00c9DICA CONFIDENCIAL<\/h5>\n<p>Yo, <span class=\"wpcf7-form-control-wrap nombreAutorizo\"><input type=\"text\" name=\"nombreAutorizo\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> autorizo a los adultos que nombro enseguida para llevar a mi hijo\/a y discutir la informaci\u00f3n necesaria con el m\u00e9dico de Children\u2019s Cardiovascular<br \/>\n        Medicine &amp; Family Preventive Medicine, para el bienestar del paciente.<\/p>\n<\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombre1Paciente\"><input type=\"text\" name=\"nombre1Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Relaci\u00f3n con el Paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap relacion1Paciente\"><input type=\"text\" name=\"relacion1Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relaci\u00f3n con el Paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefono1Paciente\"><input type=\"number\" name=\"telefono1Paciente\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombre2Paciente\"><input type=\"text\" name=\"nombre2Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Relaci\u00f3n con el Paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap relacion2Paciente\"><input type=\"text\" name=\"relacion2Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relaci\u00f3n con el Paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefono2Paciente\"><input type=\"number\" name=\"telefono2Paciente\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Nombre:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombre3Paciente\"><input type=\"text\" name=\"nombre3Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Relaci\u00f3n con el Paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap relacion3Paciente\"><input type=\"text\" name=\"relacion3Paciente\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relaci\u00f3n con el Paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-4\">\n        <label for=\"inputEmail4\">Tel\u00e9fono:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap telefono3Paciente\"><input type=\"number\" name=\"telefono3Paciente\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<p>Doy mi consentimiento a Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine para solicitar o dar a conocer Informaci\u00f3n Medica confidencial (PHI), con el prop\u00f3sito de proporcionar cuidado medico o, para efectos de pagos por tratamiento medico. (TPO). Para una completa informaci\u00f3n del manejo de su historia cl\u00ednica, pida a Children\u2019s Cardiovascular Medicine PC. Una copia del reglamento de privacidad.<\/p>\n<p>Tengo el derecho de revisar el reglamento de privacidad, antes de firmar \u00e9sta autorizaci\u00f3n. Doy mi autorizaci\u00f3n para que Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine llame a mi casa o a cualquiera de los tel\u00e9fonos que he escrito en las formas, para dejar mensajes en grabadoras o hablar en persona acerca de: cuidado cl\u00ednico incluyendo ex\u00e1menes de laboratorio, resultados de monitores o citas m\u00e9dicas.<\/p>\n<p>Doy mi autorizaci\u00f3n para que Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine envi\u00e9 por correo a la direcci\u00f3n que he escrito en las formas, cuentas de cobro (TPO), recordatorios de citas siempre y cuando sean marcadas como personal y confidencial.<\/p>\n<p>Doy mi autorizaci\u00f3n para que Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine para que env\u00ede a mi correo electr\u00f3nico, recordatorios de citas y cuentas de cobro. Tengo el derecho de decir a Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine como manejar informaci\u00f3n para proporcionar PHI o TPO. Sin embargo, la pr\u00e1ctica no necesita estar de acuerdo con las restricciones que imponga, pero si lo est\u00e1, ser\u00e1 de acuerdo a los l\u00edmites de este documento.<\/p>\n<p>Al firmar este documento, doy mi autorizaci\u00f3n a Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine, para que use y proporcione mi PHI para llevar a cabo el TPO.<\/p>\n<p>Sin la firma de esta autorizaci\u00f3n Children\u2019s Cardiovascular Medicine &amp; Family Preventive Medicine, no podr\u00e1 suministrar ning\u00fan tratamiento.<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Firma del Padre\/madre o guardi\u00e1n legal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap firmaAutori\"><input type=\"text\" name=\"firmaAutori\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Firma del Padre\/madre o guardi\u00e1n legal\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Fecha:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechaAutori\"><input type=\"date\" name=\"fechaAutori\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha\" \/><\/span>\n    <\/div>\n<div class=\"w-100\"><\/div>\n<div class=\"form-group col-md-12\">\n        <label for=\"inputEmail4\">Nombre escrito del Padre \/ madre o guardi\u00e1n legal:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreAutori\"><input type=\"text\" name=\"nombreAutori\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre escrito del Padre \/ madre o guardi\u00e1n legal\" \/><\/span>\n    <\/div>\n<div class=\"w-100\"><\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del Paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombrePacAutori\"><input type=\"text\" name=\"nombrePacAutori\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del Paciente\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>ACUSE DE RECIBO DE<br\/><br \/>\n        AVISO DE PR\u00c1CTICAS DE PRIVACIDAD<\/h5>\n<p>&quot;Puede negarse a firmar este acuse de recibo&quot;<\/p>\n<\/div>\n<div class=\"col-12\">\n<p>Yo, <span class=\"wpcf7-form-control-wrap nombreRecibo\"><input type=\"text\" name=\"nombreRecibo\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> he sido informado de las pr\u00e1cticas de privacidad de esta oficina.<\/p>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Firma:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap firmaRecibo\"><input type=\"text\" name=\"firmaRecibo\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Firma\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre en letra de imprenta:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreRecibo\"><input type=\"text\" name=\"nombreRecibo\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre en letra de imprenta\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">Nombre del Paciente:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap nombreRecibo\"><input type=\"text\" name=\"nombreRecibo\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre del Paciente\" \/><\/span>\n    <\/div>\n<div class=\"form-group col-md-6\">\n        <label for=\"inputEmail4\">fecha de nacimiento:<\/label><br \/>\n        <span class=\"wpcf7-form-control-wrap fechaRecibo\"><input type=\"date\" name=\"fechaRecibo\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de nacimiento\" \/><\/span>\n    <\/div>\n<div class=\"col-12\">\n<h5>S\u00d3LO PARA USO INTERNO<\/h5>\n<h6>Hemos intentado obtener acuse de recibo escrito de nuestro Aviso de pr\u00e1cticas de privacidad,<br \/>\npero no se pudo obtener porque:<\/h6>\n<\/div>\n<div class=\"form-group col-md-6\">\n        <span class=\"wpcf7-form-control-wrap solouso\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"solouso[]\" value=\"La persona se neg\u00f3 a firmar\" \/><span class=\"wpcf7-list-item-label\">La persona se neg\u00f3 a firmar<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"solouso[]\" value=\"Barreras comunicativas impidieron obtener el acuse de recibo\" \/><span class=\"wpcf7-list-item-label\">Barreras comunicativas impidieron obtener el acuse de recibo<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"solouso[]\" value=\"Una situaci\u00f3n de emergencia nos ha impedido obtenerlo\" \/><span class=\"wpcf7-list-item-label\">Una situaci\u00f3n de emergencia nos ha impedido obtenerlo<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"solouso[]\" value=\"Otro motivo (especifique)\" \/><span class=\"wpcf7-list-item-label\">Otro motivo (especifique)<\/span><\/span><\/span><\/span>\n    <\/div>\n<\/div>\n<p><input type=\"submit\" value=\"Enviar\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/p>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3781"}],"collection":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/comments?post=3781"}],"version-history":[{"count":2,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3781\/revisions"}],"predecessor-version":[{"id":4876,"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/pages\/3781\/revisions\/4876"}],"wp:attachment":[{"href":"https:\/\/www.childrenscvm.com\/es\/wp-json\/wp\/v2\/media?parent=3781"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}