{"id":18289,"date":"2026-05-21T21:29:34","date_gmt":"2026-05-22T01:29:34","guid":{"rendered":"https:\/\/enspirefx.com\/Sharma\/"},"modified":"2026-06-25T19:44:43","modified_gmt":"2026-06-25T23:44:43","slug":"formularios-de-admision-de-pacientes","status":"publish","type":"page","link":"https:\/\/sharmarehab.com\/es\/formularios-de-admision-de-pacientes\/","title":{"rendered":"Formularios de admisi\u00f3n de pacientes"},"content":{"rendered":"<style>.kb-row-layout-id18289_56c349-2f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18289_56c349-2f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18289_56c349-2f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:var( --global-content-width, 1290px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:219px;padding-right:20px;padding-bottom:80px;padding-left:20px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18289_56c349-2f{background-image:url('https:\/\/sharmarehab.com\/wp-content\/uploads\/2025\/04\/Physical-Therapy-in-Queens-NY-1.jpeg');background-size:cover;background-position:31% 50%;background-attachment:scroll;background-repeat:no-repeat;}.kb-row-layout-id18289_56c349-2f > .kt-row-layout-overlay{opacity:0.42;background-color:var(--global-palette3, #1A202C);mix-blend-mode:normal;}@media all and (max-width: 1024px){.kb-row-layout-id18289_56c349-2f > .kt-row-column-wrap{padding-top:80px;padding-bottom:80px;grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18289_56c349-2f > .kt-row-column-wrap{padding-top:100px;padding-right:30px;padding-bottom:100px;padding-left:30px;grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18289_56c349-2f alignnone kt-row-has-bg wp-block-kadence-rowlayout\"><div class=\"kt-row-layout-overlay kt-row-overlay-normal\"><\/div><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top kb-theme-content-width\">\n<style>.kadence-column18289_3a1baf-80 > .kt-inside-inner-col,.kadence-column18289_3a1baf-80 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_3a1baf-80 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_3a1baf-80 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_3a1baf-80 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_3a1baf-80 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_3a1baf-80{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_3a1baf-80 > .kt-inside-inner-col{padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_3a1baf-80 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_3a1baf-80 inner-column-1\"><div class=\"kt-inside-inner-col\"><style>.kb-row-layout-id18289_bf20bc-4f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18289_bf20bc-4f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18289_bf20bc-4f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:600px;margin-left:auto;margin-right:auto;padding-top:0px;padding-bottom:0px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18289_bf20bc-4f > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18289_bf20bc-4f > .kt-row-column-wrap{padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18289_bf20bc-4f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18289_bf20bc-4f alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18289_2cffda-ec > .kt-inside-inner-col{padding-right:40px;padding-left:40px;}.kadence-column18289_2cffda-ec > .kt-inside-inner-col,.kadence-column18289_2cffda-ec > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_2cffda-ec > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_2cffda-ec > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_2cffda-ec > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_2cffda-ec > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_2cffda-ec{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_2cffda-ec > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_2cffda-ec > .kt-inside-inner-col{padding-right:0px;padding-left:0px;flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_2cffda-ec inner-column-1\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7, .wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7[data-kb-block=\"kb-adv-heading18289_dfa578-c7\"]{padding-top:0px;padding-right:0px;padding-bottom:20px;padding-left:0px;margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;text-align:center;font-style:normal;text-transform:capitalize;}.wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7[data-kb-block=\"kb-adv-heading18289_dfa578-c7\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18289_dfa578-c7[data-kb-block=\"kb-adv-heading18289_dfa578-c7\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h1 class=\"kt-adv-heading18289_dfa578-c7 wp-block-kadence-advancedheading has-theme-palette-7-color has-text-color\" data-kb-block=\"kb-adv-heading18289_dfa578-c7\">Patient Intake<\/h1>\n<\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18289_57e6d4-e1 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18289_57e6d4-e1 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18289_57e6d4-e1 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-lg, 4rem);row-gap:var(--global-kb-gap-lg, 4rem);max-width:var( --global-content-width, 1290px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:var(--global-kb-spacing-lg, 3rem);padding-bottom:var(--global-kb-spacing-xxl, 5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18289_57e6d4-e1 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18289_57e6d4-e1 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-xxl, 5rem);grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18289_57e6d4-e1 > .kt-row-column-wrap{padding-top:var(--global-kb-spacing-xs, 1rem);padding-bottom:var(--global-kb-spacing-md, 2rem);grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18289_57e6d4-e1 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top kb-theme-content-width\">\n<style>.kadence-column18289_2df859-86 > .kt-inside-inner-col{display:flex;}#wrapper.site{overflow:clip;}.kadence-column18289_2df859-86 > .kt-inside-inner-col{padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kadence-column18289_2df859-86 > .kt-inside-inner-col,.kadence-column18289_2df859-86 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_2df859-86 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_2df859-86 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;align-items:center;}.kadence-column18289_2df859-86 > .kt-inside-inner-col > .kb-image-is-ratio-size{align-self:stretch;}.kadence-column18289_2df859-86 > .kt-inside-inner-col > .wp-block-kadence-advancedgallery{align-self:stretch;}.kadence-column18289_2df859-86 > .kt-inside-inner-col > .aligncenter{width:100%;}.kt-row-column-wrap > .kadence-column18289_2df859-86{align-self:flex-start;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}.kadence-column18289_2df859-86 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_2df859-86{position:relative;}.kadence-column18289_2df859-86, .kt-inside-inner-col > .kadence-column18289_2df859-86:not(.specificity){margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;}@media all and (max-width: 1024px){.kadence-column18289_2df859-86 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-sm, 1.5rem);flex-direction:column;justify-content:flex-start;align-items:center;}}@media all and (max-width: 1024px){.kt-row-column-wrap > .kadence-column18289_2df859-86{align-self:flex-start;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86{align-self:auto;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}}@media all and (max-width: 767px){.kadence-column18289_2df859-86 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-md, 2rem);flex-direction:column;justify-content:flex-start;align-items:center;}.kt-row-column-wrap > .kadence-column18289_2df859-86{align-self:flex-start;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column18289_2df859-86 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_2df859-86 kb-section-is-sticky\"><div class=\"kt-inside-inner-col\"><style>.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col,.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_8c6dba-e7{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_8c6dba-e7 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_8c6dba-e7\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4, .wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4[data-kb-block=\"kb-adv-heading18289_323d70-a4\"]{text-align:left;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4[data-kb-block=\"kb-adv-heading18289_323d70-a4\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18289_323d70-a4[data-kb-block=\"kb-adv-heading18289_323d70-a4\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<p class=\"kt-adv-heading18289_323d70-a4 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18289_323d70-a4\">Select Intake form language<\/p>\n\n\n<style>.kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .wp-block-kadence-tab{border-top:3px solid var(--global-palette7, #EDF2F7);border-right:0px solid #0a6689;border-bottom:0px solid #0a6689;border-left:0px solid #0a6689;border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;background:var(--global-palette9, #ffffff);}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-title-list li{margin-top:0px;margin-right:8px;margin-bottom:0px;margin-left:0px;}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-title-list li:last-child{margin-right:0px;}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-title-list li .kt-tab-title, .wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .kt-tabs-accordion-title .kt-tab-title{line-height:1.4em;font-weight:regular;font-style:normal;border-top-width:0px;border-right-width:0px;border-bottom-width:0px;border-left-width:0px;border-top-left-radius:4px;border-top-right-radius:4px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;padding-top:8px;padding-right:20px;padding-bottom:8px;padding-left:20px;border-color:var(--global-palette7, #eeeeee);color:var(--global-palette8, #F7FAFC);background:var(--global-palette5, #4A5568);}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .kt-tabs-accordion-title .kt-tab-title{margin-top:0px;margin-right:8px;margin-bottom:0px;margin-left:0px;}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-title-list li .kt-tab-title:hover, .wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .kt-tabs-accordion-title .kt-tab-title:hover{border-color:var(--global-palette7, #eeeeee);color:var(--global-palette5, #4A5568);background:var(--global-palette7, #EDF2F7);}.wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-title-list li.kt-tab-title-active .kt-tab-title, .wp-block-kadence-tabs .kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .kt-tabs-accordion-title.kt-tab-title-active .kt-tab-title{border-color:var(--global-palette7, #eeeeee);color:var(--global-palette3, #1A202C);background:var(--global-palette7, #EDF2F7);}@media all and (max-width: 1024px){.kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .wp-block-kadence-tab{border-top:3px solid var(--global-palette7, #EDF2F7);border-right:0px solid #0a6689;border-bottom:0px solid #0a6689;border-left:0px solid #0a6689;}}@media all and (max-width: 767px){.kt-tabs-id18289_bccc12-d3 > .kt-tabs-content-wrap > .wp-block-kadence-tab{border-top:3px solid var(--global-palette7, #EDF2F7);border-right:0px solid #0a6689;border-bottom:0px solid #0a6689;border-left:0px solid #0a6689;}}<\/style>\n<div class=\"wp-block-kadence-tabs alignnone\"><div class=\"kt-tabs-wrap kt-tabs-id18289_bccc12-d3 kt-tabs-has-2-tabs kt-active-tab-2 kt-tabs-layout-tabs kt-tabs-tablet-layout-inherit kt-tabs-mobile-layout-inherit kt-tab-alignment-left \"><ul class=\"kt-tabs-title-list\"><li id=\"tab-english\" class=\"kt-title-item kt-title-item-1 kt-tabs-svg-show-always kt-tabs-icon-side-right kt-tab-title-inactive\"><a href=\"#tab-english\" data-tab=\"1\" class=\"kt-tab-title kt-tab-title-1 \"><span class=\"kt-title-text\">English<\/span><\/a><\/li><li id=\"tab-spanish\" class=\"kt-title-item kt-title-item-2 kt-tabs-svg-show-always kt-tabs-icon-side-right kt-tab-title-active\"><a href=\"#tab-spanish\" data-tab=\"2\" class=\"kt-tab-title kt-tab-title-2 \"><span class=\"kt-title-text\">Spanish<\/span><\/a><\/li><\/ul><div class=\"kt-tabs-content-wrap\">\n<div class=\"wp-block-kadence-tab kt-tab-inner-content kt-inner-tab-1 kt-inner-tab18289_4fc244-1d\"><div class=\"kt-tab-inner-content-inner\"><style>.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-lg, 3rem);padding-right:var(--global-kb-spacing-lg, 3rem);padding-bottom:var(--global-kb-spacing-lg, 3rem);padding-left:var(--global-kb-spacing-lg, 3rem);}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col,.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{background-color:var(--global-palette7, #EDF2F7);}.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_e09fd4-d1{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-right:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);padding-left:var(--global-kb-spacing-sm, 1.5rem);flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_e09fd4-d1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_e09fd4-d1\"><div class=\"kt-inside-inner-col\"><div class=\"wp-block-kadence-advanced-form wp-block-kadence-advanced-form18297-cpt-id kb-adv-form-label-style-normal kb-adv-form-input-size-standard kb-form-basic-style\"><form id=\"kb-adv-form-18297-cpt-id\" class=\"kb-advanced-form\" method=\"post\" data-kb-events=\"yes\">\n<style>.kadence-column18297_145be1-fd > .kt-inside-inner-col{display:flex;}.kadence-column18297_145be1-fd > .kt-inside-inner-col,.kadence-column18297_145be1-fd > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_145be1-fd > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_145be1-fd > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_145be1-fd > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_145be1-fd > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_145be1-fd{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_145be1-fd > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_145be1-fd > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_145be1-fd\"><div class=\"kt-inside-inner-col\">\n<p class=\"wp-block-paragraph\">Please provide the following information. This form is confidential &amp; will be entered into your records\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5, .wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5[data-kb-block=\"kb-adv-heading18297_9cb6a6-a5\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5[data-kb-block=\"kb-adv-heading18297_9cb6a6-a5\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_9cb6a6-a5[data-kb-block=\"kb-adv-heading18297_9cb6a6-a5\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18297_9cb6a6-a5 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_9cb6a6-a5\">STEP 1: Patient Information<\/h2>\n\n\n<style>.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18297_c8a81c-47 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_c8a81c-47 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_c8a81c-47 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_919472-1a > .kt-inside-inner-col,.kadence-column18297_919472-1a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_919472-1a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_919472-1a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_919472-1a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_919472-1a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_919472-1a{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_919472-1a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_919472-1a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_919472-1a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297179e62-01 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297179e62-01\">First Name<\/label><input name=\"field179e62-01\" id=\"field18297179e62-01\" data-label=\"First Name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_0fc015-f2 > .kt-inside-inner-col,.kadence-column18297_0fc015-f2 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_0fc015-f2 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_0fc015-f2 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_0fc015-f2 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_0fc015-f2 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_0fc015-f2{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_0fc015-f2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_0fc015-f2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_0fc015-f2\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297e3d284-a3 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297e3d284-a3\">Last name<\/label><input name=\"fielde3d284-a3\" id=\"field18297e3d284-a3\" data-label=\"Last name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_1672db-ec > .kt-inside-inner-col,.kadence-column18297_1672db-ec > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_1672db-ec > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_1672db-ec > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_1672db-ec > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_1672db-ec > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_1672db-ec{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_1672db-ec > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_1672db-ec > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_1672db-ec\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18297142eab-7c wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field18297142eab-7c\">Date of Birth<\/label><input name=\"field142eab-7c\" id=\"field18297142eab-7c\" data-label=\"Date of Birth\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18297_282c35-83 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_282c35-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_282c35-83 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_066ef0-dd > .kt-inside-inner-col,.kadence-column18297_066ef0-dd > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_066ef0-dd > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_066ef0-dd > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_066ef0-dd > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_066ef0-dd > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_066ef0-dd{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_066ef0-dd > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_066ef0-dd > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_066ef0-dd\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18297f8562c-27 wp-block-kadence-advanced-form-select\"><label class=\"kb-adv-form-label\" for=\"field18297f8562c-27\">Birth Sex<\/label><select  name=\"fieldf8562c-27\" id=\"field18297f8562c-27\" ><option value=\"\" disabled selected>Select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_b771aa-31 > .kt-inside-inner-col,.kadence-column18297_b771aa-31 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_b771aa-31 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_b771aa-31 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_b771aa-31 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_b771aa-31 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_b771aa-31{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_b771aa-31 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_b771aa-31 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_b771aa-31\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182970c74d1-47 wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field182970c74d1-47\">Social Security #<\/label><input name=\"field0c74d1-47\" id=\"field182970c74d1-47\" data-label=\"Social Security #\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_84d8ee-35 > .kt-inside-inner-col,.kadence-column18297_84d8ee-35 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_84d8ee-35 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_84d8ee-35 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_84d8ee-35 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_84d8ee-35 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_84d8ee-35{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_84d8ee-35 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_84d8ee-35 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_84d8ee-35\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829716c686-cc wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field1829716c686-cc\">Phone Number<\/label><input name=\"field16c686-cc\" id=\"field1829716c686-cc\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_7c320f-7f > .kt-inside-inner-col,.kadence-column18297_7c320f-7f > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_7c320f-7f > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_7c320f-7f > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_7c320f-7f > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_7c320f-7f > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_7c320f-7f{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_7c320f-7f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_7c320f-7f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_7c320f-7f\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297db344b-08 wp-block-kadence-advanced-form-email\"><label class=\"kb-adv-form-label\" for=\"field18297db344b-08\">Email Address<\/label><input name=\"fielddb344b-08\" id=\"field18297db344b-08\" data-label=\"Email Address\" type=\"email\" placeholder=\"\" value=\"\" data-type=\"email\" class=\"kb-field kb-email-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18297_62dc48-4c > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_62dc48-4c > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_62dc48-4c alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col,.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_9cf0ca-9b{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_9cf0ca-9b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_9cf0ca-9b\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182974fdaa1-b5 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field182974fdaa1-b5\">Address<\/label><input name=\"field4fdaa1-b5\" id=\"field182974fdaa1-b5\" data-label=\"Address\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col,.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_4f7e8d-f8{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_4f7e8d-f8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_4f7e8d-f8\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297b226a4-8a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297b226a4-8a\">City<\/label><input name=\"fieldb226a4-8a\" id=\"field18297b226a4-8a\" data-label=\"City\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col,.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_dcdb3d-3d{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_dcdb3d-3d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_dcdb3d-3d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297fa0f61-07 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297fa0f61-07\">State<\/label><input name=\"fieldfa0f61-07\" id=\"field18297fa0f61-07\" data-label=\"State\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_9ec055-c6 > .kt-inside-inner-col,.kadence-column18297_9ec055-c6 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_9ec055-c6 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_9ec055-c6 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_9ec055-c6 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_9ec055-c6 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_9ec055-c6{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_9ec055-c6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_9ec055-c6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_9ec055-c6\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297154a6f-eb wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297154a6f-eb\">Zipcode<\/label><input name=\"field154a6f-eb\" id=\"field18297154a6f-eb\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}.kb-row-layout-id18297_62623a-93 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_62623a-93 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_62623a-93 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_5075e5-16 > .kt-inside-inner-col,.kadence-column18297_5075e5-16 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_5075e5-16 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_5075e5-16 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_5075e5-16 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_5075e5-16 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_5075e5-16{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_5075e5-16 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_5075e5-16 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_5075e5-16\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182978c94ac-b1 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field182978c94ac-b1\">Marital status<\/label><input name=\"field8c94ac-b1\" id=\"field182978c94ac-b1\" data-label=\"Marital status\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_8419a1-4a > .kt-inside-inner-col,.kadence-column18297_8419a1-4a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_8419a1-4a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_8419a1-4a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_8419a1-4a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_8419a1-4a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_8419a1-4a{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_8419a1-4a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_8419a1-4a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_8419a1-4a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297273cb8-7f wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297273cb8-7f\">Emergency contact<\/label><input name=\"field273cb8-7f\" id=\"field18297273cb8-7f\" data-label=\"Emergency contact\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_cd30d3-54 > .kt-inside-inner-col,.kadence-column18297_cd30d3-54 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_cd30d3-54 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_cd30d3-54 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_cd30d3-54 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_cd30d3-54 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_cd30d3-54{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_cd30d3-54 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_cd30d3-54 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_cd30d3-54\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182977a0172-b9 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field182977a0172-b9\">Relationship<\/label><input name=\"field7a0172-b9\" id=\"field182977a0172-b9\" data-label=\"Relationship\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_546cd7-d7 > .kt-inside-inner-col,.kadence-column18297_546cd7-d7 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_546cd7-d7 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_546cd7-d7 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_546cd7-d7 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_546cd7-d7 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_546cd7-d7{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_546cd7-d7 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_546cd7-d7 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_546cd7-d7\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182972316cd-88 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field182972316cd-88\">Phone Number<\/label><input name=\"field2316cd-88\" id=\"field182972316cd-88\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_30c5f5-0e > .kt-inside-inner-col{display:flex;}.kadence-column18297_30c5f5-0e > .kt-inside-inner-col,.kadence-column18297_30c5f5-0e > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_30c5f5-0e > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_30c5f5-0e > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_30c5f5-0e > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_30c5f5-0e > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_30c5f5-0e{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_30c5f5-0e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_30c5f5-0e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_30c5f5-0e\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4, .wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4[data-kb-block=\"kb-adv-heading18297_17b656-b4\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4[data-kb-block=\"kb-adv-heading18297_17b656-b4\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_17b656-b4[data-kb-block=\"kb-adv-heading18297_17b656-b4\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18297_17b656-b4 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_17b656-b4\"><strong>Insurance name<\/strong><\/h2>\n\n\n<style>.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}.kb-row-layout-id18297_93a0bb-c9 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_93a0bb-c9 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_93a0bb-c9 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_a837da-15 > .kt-inside-inner-col,.kadence-column18297_a837da-15 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_a837da-15 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_a837da-15 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_a837da-15 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_a837da-15 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_a837da-15{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_a837da-15 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_a837da-15 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_a837da-15\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182975518b2-16 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field182975518b2-16\">Insurance name<\/label><input name=\"field5518b2-16\" id=\"field182975518b2-16\" data-label=\"Insurance name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_5ef095-b8 > .kt-inside-inner-col,.kadence-column18297_5ef095-b8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_5ef095-b8 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_5ef095-b8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_5ef095-b8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_5ef095-b8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_5ef095-b8{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_5ef095-b8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_5ef095-b8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_5ef095-b8\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297946527-04 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297946527-04\">Insurance name<\/label><input name=\"field946527-04\" id=\"field18297946527-04\" data-label=\"Insurance name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_c34ab4-3e > .kt-inside-inner-col,.kadence-column18297_c34ab4-3e > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_c34ab4-3e > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_c34ab4-3e > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_c34ab4-3e > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_c34ab4-3e > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_c34ab4-3e{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_c34ab4-3e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_c34ab4-3e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_c34ab4-3e\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829748750b-8e wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1829748750b-8e\">Policyholder&#8217;s name<\/label><input name=\"field48750b-8e\" id=\"field1829748750b-8e\" data-label=\"Policyholder&#039;s name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_28c554-ef > .kt-inside-inner-col,.kadence-column18297_28c554-ef > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_28c554-ef > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_28c554-ef > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_28c554-ef > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_28c554-ef > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_28c554-ef{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_28c554-ef > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_28c554-ef > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_28c554-ef\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18297310a03-15 wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field18297310a03-15\">Date of birth<\/label><input name=\"field310a03-15\" id=\"field18297310a03-15\" data-label=\"Date of birth\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18297_b79f87-8f > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_b79f87-8f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_b79f87-8f alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_09e7d3-1c > .kt-inside-inner-col,.kadence-column18297_09e7d3-1c > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_09e7d3-1c > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_09e7d3-1c > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_09e7d3-1c > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_09e7d3-1c > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_09e7d3-1c{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_09e7d3-1c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_09e7d3-1c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_09e7d3-1c\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18297a29fcb-1f wp-block-kadence-advanced-form-select\"><label class=\"kb-adv-form-label\" for=\"field18297a29fcb-1f\">Do you have a secondary insurance?<\/label><select  name=\"fielda29fcb-1f\" id=\"field18297a29fcb-1f\" ><option value=\"\" disabled selected>Select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_818faa-77 > .kt-inside-inner-col,.kadence-column18297_818faa-77 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_818faa-77 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_818faa-77 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_818faa-77 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_818faa-77 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_818faa-77{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_818faa-77 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_818faa-77 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_818faa-77\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829787ae31-ef wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1829787ae31-ef\">Insurance name<\/label><input name=\"field87ae31-ef\" id=\"field1829787ae31-ef\" data-label=\"Insurance name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_b761db-4e > .kt-inside-inner-col,.kadence-column18297_b761db-4e > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_b761db-4e > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_b761db-4e > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_b761db-4e > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_b761db-4e > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_b761db-4e{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_b761db-4e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_b761db-4e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_b761db-4e\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297503c49-4b wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field18297503c49-4b\">Insurance ID #<\/label><input name=\"field503c49-4b\" id=\"field18297503c49-4b\" data-label=\"Insurance ID #\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_e633e5-76 > .kt-inside-inner-col,.kadence-column18297_e633e5-76 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_e633e5-76 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_e633e5-76 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_e633e5-76 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_e633e5-76 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_e633e5-76{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_e633e5-76 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_e633e5-76 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_e633e5-76\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297b9615d-5b wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297b9615d-5b\">Policyholder&#8217;s name<\/label><input name=\"fieldb9615d-5b\" id=\"field18297b9615d-5b\" data-label=\"Policyholder&#039;s name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col{display:flex;}.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col,.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_5b1f24-e8{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_5b1f24-e8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_5b1f24-e8\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2, .wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2[data-kb-block=\"kb-adv-heading18297_4e889e-a2\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2[data-kb-block=\"kb-adv-heading18297_4e889e-a2\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_4e889e-a2[data-kb-block=\"kb-adv-heading18297_4e889e-a2\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18297_4e889e-a2 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_4e889e-a2\">STEP 3: Workers\u2019 Comp \/ No-Fault Patient Only<\/h2>\n\n\n<style>.kb-row-layout-id18297_9346f6-19 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_9346f6-19 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_9346f6-19 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18297_9346f6-19 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_9346f6-19 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_9346f6-19 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_9346f6-19 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_92e043-4b > .kt-inside-inner-col,.kadence-column18297_92e043-4b > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_92e043-4b > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_92e043-4b > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_92e043-4b > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_92e043-4b > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_92e043-4b{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_92e043-4b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_92e043-4b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_92e043-4b\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297ed6a80-2b wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297ed6a80-2b\">Employers name<\/label><input name=\"fielded6a80-2b\" id=\"field18297ed6a80-2b\" data-label=\"Employers name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_f899d5-ec > .kt-inside-inner-col,.kadence-column18297_f899d5-ec > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_f899d5-ec > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_f899d5-ec > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_f899d5-ec > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_f899d5-ec > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_f899d5-ec{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_f899d5-ec > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_f899d5-ec > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_f899d5-ec\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297495cbd-5e wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18297495cbd-5e\">Phone Number<\/label><input name=\"field495cbd-5e\" id=\"field18297495cbd-5e\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18297_0fb510-c1 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_0fb510-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_0fb510-c1 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_f5f778-a8 > .kt-inside-inner-col,.kadence-column18297_f5f778-a8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_f5f778-a8 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_f5f778-a8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_f5f778-a8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_f5f778-a8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_f5f778-a8{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_f5f778-a8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_f5f778-a8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_f5f778-a8\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297a4301f-57 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297a4301f-57\">Address<\/label><input name=\"fielda4301f-57\" id=\"field18297a4301f-57\" data-label=\"Address\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_75bbe5-31 > .kt-inside-inner-col,.kadence-column18297_75bbe5-31 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_75bbe5-31 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_75bbe5-31 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_75bbe5-31 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_75bbe5-31 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_75bbe5-31{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_75bbe5-31 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_75bbe5-31 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_75bbe5-31\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297d663ce-36 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297d663ce-36\">City<\/label><input name=\"fieldd663ce-36\" id=\"field18297d663ce-36\" data-label=\"City\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_4fa925-0d > .kt-inside-inner-col,.kadence-column18297_4fa925-0d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_4fa925-0d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_4fa925-0d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_4fa925-0d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_4fa925-0d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_4fa925-0d{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_4fa925-0d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_4fa925-0d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_4fa925-0d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297a5514b-92 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297a5514b-92\">State<\/label><input name=\"fielda5514b-92\" id=\"field18297a5514b-92\" data-label=\"State\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_73848c-41 > .kt-inside-inner-col,.kadence-column18297_73848c-41 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_73848c-41 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_73848c-41 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_73848c-41 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_73848c-41 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_73848c-41{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_73848c-41 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_73848c-41 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_73848c-41\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182979c4707-50 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field182979c4707-50\">Zipcode<\/label><input name=\"field9c4707-50\" id=\"field182979c4707-50\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18297_22d634-47 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_22d634-47 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_22d634-47 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_0032ba-78 > .kt-inside-inner-col,.kadence-column18297_0032ba-78 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_0032ba-78 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_0032ba-78 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_0032ba-78 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_0032ba-78 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_0032ba-78{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_0032ba-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_0032ba-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_0032ba-78\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297c443a4-ea wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field18297c443a4-ea\">Claim #<\/label><input name=\"fieldc443a4-ea\" id=\"field18297c443a4-ea\" data-label=\"Claim #\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col,.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_0c5c2e-03{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_0c5c2e-03 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_0c5c2e-03\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829728d752-d2 wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field1829728d752-d2\">WCB #<\/label><input name=\"field28d752-d2\" id=\"field1829728d752-d2\" data-label=\"WCB #\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_7eac99-d6 > .kt-inside-inner-col,.kadence-column18297_7eac99-d6 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_7eac99-d6 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_7eac99-d6 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_7eac99-d6 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_7eac99-d6 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_7eac99-d6{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_7eac99-d6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_7eac99-d6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_7eac99-d6\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297ba08ab-af wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297ba08ab-af\">Carrier Case #<\/label><input name=\"fieldba08ab-af\" id=\"field18297ba08ab-af\" data-label=\"Carrier Case #\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18297_a4a1d4-5d > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_a4a1d4-5d > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_a4a1d4-5d alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_1ef272-99 > .kt-inside-inner-col,.kadence-column18297_1ef272-99 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_1ef272-99 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_1ef272-99 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_1ef272-99 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_1ef272-99 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_1ef272-99{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_1ef272-99 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_1ef272-99 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_1ef272-99\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297491ead-07 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297491ead-07\">Adjuster Name<\/label><input name=\"field491ead-07\" id=\"field18297491ead-07\" data-label=\"Adjuster Name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_95f8b8-dc > .kt-inside-inner-col,.kadence-column18297_95f8b8-dc > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_95f8b8-dc > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_95f8b8-dc > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_95f8b8-dc > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_95f8b8-dc > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_95f8b8-dc{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_95f8b8-dc > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_95f8b8-dc > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_95f8b8-dc\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297677993-6e wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18297677993-6e\">Phone Number<\/label><input name=\"field677993-6e\" id=\"field18297677993-6e\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col,.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_8a0c1e-58{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_8a0c1e-58 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_8a0c1e-58\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297d4b411-24 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18297d4b411-24\">Fax number<\/label><input name=\"fieldd4b411-24\" id=\"field18297d4b411-24\" data-label=\"Fax number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18297_a49b50-60 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_a49b50-60 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_a49b50-60 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_8c18cd-1a > .kt-inside-inner-col,.kadence-column18297_8c18cd-1a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_8c18cd-1a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_8c18cd-1a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_8c18cd-1a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_8c18cd-1a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_8c18cd-1a{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_8c18cd-1a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_8c18cd-1a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_8c18cd-1a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297fe302a-9b wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297fe302a-9b\">Attorney Name<\/label><input name=\"fieldfe302a-9b\" id=\"field18297fe302a-9b\" data-label=\"Attorney Name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_d33fcf-91 > .kt-inside-inner-col,.kadence-column18297_d33fcf-91 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_d33fcf-91 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_d33fcf-91 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_d33fcf-91 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_d33fcf-91 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_d33fcf-91{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_d33fcf-91 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_d33fcf-91 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_d33fcf-91\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297750fef-5b wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18297750fef-5b\">Phone Number<\/label><input name=\"field750fef-5b\" id=\"field18297750fef-5b\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_3f64fe-cf > .kt-inside-inner-col,.kadence-column18297_3f64fe-cf > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_3f64fe-cf > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_3f64fe-cf > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_3f64fe-cf > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_3f64fe-cf > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_3f64fe-cf{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_3f64fe-cf > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_3f64fe-cf > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_3f64fe-cf\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829785bc20-71 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field1829785bc20-71\">Fax number<\/label><input name=\"field85bc20-71\" id=\"field1829785bc20-71\" data-label=\"Fax number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_ec24af-95 > .kt-inside-inner-col{display:flex;}.kadence-column18297_ec24af-95 > .kt-inside-inner-col,.kadence-column18297_ec24af-95 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_ec24af-95 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_ec24af-95 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_ec24af-95 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_ec24af-95 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_ec24af-95{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_ec24af-95 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_ec24af-95 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_ec24af-95\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3, .wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3[data-kb-block=\"kb-adv-heading18297_6fbc33-e3\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3[data-kb-block=\"kb-adv-heading18297_6fbc33-e3\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_6fbc33-e3[data-kb-block=\"kb-adv-heading18297_6fbc33-e3\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18297_6fbc33-e3 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_6fbc33-e3\">STEP 4: Primary care or referring physician information<\/h2>\n\n\n<style>.kb-row-layout-id18297_77d75a-a2 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_77d75a-a2 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_77d75a-a2 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18297_77d75a-a2 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_77d75a-a2 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_77d75a-a2 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_77d75a-a2 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_817a29-89 > .kt-inside-inner-col,.kadence-column18297_817a29-89 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_817a29-89 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_817a29-89 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_817a29-89 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_817a29-89 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_817a29-89{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_817a29-89 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_817a29-89 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_817a29-89\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829705e7b2-d8 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1829705e7b2-d8\">Name<\/label><input name=\"field05e7b2-d8\" id=\"field1829705e7b2-d8\" data-label=\"Name\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_df6d76-04 > .kt-inside-inner-col,.kadence-column18297_df6d76-04 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_df6d76-04 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_df6d76-04 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_df6d76-04 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_df6d76-04 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_df6d76-04{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_df6d76-04 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_df6d76-04 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_df6d76-04\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field182978e9729-a5 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field182978e9729-a5\">Phone Number<\/label><input name=\"field8e9729-a5\" id=\"field182978e9729-a5\" data-label=\"Phone Number\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18297_81ae2d-d7 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_81ae2d-d7 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_81ae2d-d7 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_3501cb-71 > .kt-inside-inner-col,.kadence-column18297_3501cb-71 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_3501cb-71 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_3501cb-71 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_3501cb-71 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_3501cb-71 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_3501cb-71{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_3501cb-71 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_3501cb-71 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_3501cb-71\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297c8ee18-f1 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297c8ee18-f1\">Address<\/label><input name=\"fieldc8ee18-f1\" id=\"field18297c8ee18-f1\" data-label=\"Address\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_974806-d5 > .kt-inside-inner-col,.kadence-column18297_974806-d5 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_974806-d5 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_974806-d5 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_974806-d5 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_974806-d5 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_974806-d5{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_974806-d5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_974806-d5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_974806-d5\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297c7d90d-16 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297c7d90d-16\">City<\/label><input name=\"fieldc7d90d-16\" id=\"field18297c7d90d-16\" data-label=\"City\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_365ae2-09 > .kt-inside-inner-col,.kadence-column18297_365ae2-09 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_365ae2-09 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_365ae2-09 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_365ae2-09 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_365ae2-09 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_365ae2-09{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_365ae2-09 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_365ae2-09 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_365ae2-09\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829764c68a-b5 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1829764c68a-b5\">State<\/label><input name=\"field64c68a-b5\" id=\"field1829764c68a-b5\" data-label=\"State\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_e79405-22 > .kt-inside-inner-col,.kadence-column18297_e79405-22 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_e79405-22 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_e79405-22 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_e79405-22 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_e79405-22 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_e79405-22{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_e79405-22 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_e79405-22 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_e79405-22\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829731f17c-7a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1829731f17c-7a\">Zipcode<\/label><input name=\"field31f17c-7a\" id=\"field1829731f17c-7a\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18297_f6117c-20 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_f6117c-20 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_f6117c-20 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_7d2c71-0c > .kt-inside-inner-col,.kadence-column18297_7d2c71-0c > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_7d2c71-0c > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_7d2c71-0c > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_7d2c71-0c > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_7d2c71-0c > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_7d2c71-0c{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_7d2c71-0c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_7d2c71-0c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_7d2c71-0c\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18297546709-c4 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"rb18297546709-c4\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Do you have a pacemaker implanted?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297546709-c4_0\" name=\"field546709-c4\"  value=\"Yes\"><label for=\"field18297546709-c4_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297546709-c4_1\" name=\"field546709-c4\"  value=\"No\"><label for=\"field18297546709-c4_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_aefb74-70 > .kt-inside-inner-col,.kadence-column18297_aefb74-70 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_aefb74-70 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_aefb74-70 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_aefb74-70 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_aefb74-70 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_aefb74-70{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_aefb74-70 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_aefb74-70 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_aefb74-70\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18297aabfb7-ba wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"rb18297aabfb7-ba\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Have you taken Physical therapy this year?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aabfb7-ba_0\" name=\"fieldaabfb7-ba\"  value=\"Yes\"><label for=\"field18297aabfb7-ba_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aabfb7-ba_1\" name=\"fieldaabfb7-ba\"  value=\"No\"><label for=\"field18297aabfb7-ba_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_41df4d-57 > .kt-inside-inner-col,.kadence-column18297_41df4d-57 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_41df4d-57 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_41df4d-57 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_41df4d-57 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_41df4d-57 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_41df4d-57{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_41df4d-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_41df4d-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_41df4d-57\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18297648669-74 wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field18297648669-74\">If so, When?<\/label><input name=\"field648669-74\" id=\"field18297648669-74\" data-label=\"If so, When?\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\"  data-conditional-rules=\"{&quot;container&quot;:&quot;.kb-field18297648669-74&quot;,&quot;action&quot;:&quot;show&quot;,&quot;logic&quot;:&quot;or&quot;,&quot;rules&quot;:[{&quot;name&quot;:&quot;field18297aabfb7-ba&quot;,&quot;operator&quot;:&quot;is&quot;,&quot;value&quot;:&quot;Yes&quot;}]}\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14, .wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14[data-kb-block=\"kb-adv-heading18297_e041fe-14\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14[data-kb-block=\"kb-adv-heading18297_e041fe-14\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_e041fe-14[data-kb-block=\"kb-adv-heading18297_e041fe-14\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_e041fe-14 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_e041fe-14\">Pain Assessment<\/h3>\n\n\n<style>.kb-row-layout-id18297_05473a-14 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_05473a-14 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_05473a-14 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:repeat(2, minmax(0, 1fr));}.kb-row-layout-id18297_05473a-14 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_05473a-14 > .kt-row-column-wrap{grid-template-columns:repeat(2, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_05473a-14 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_05473a-14 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col,.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_06e8f4-e5{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_06e8f4-e5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_06e8f4-e5\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18297aa48ab-0c wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18297aa48ab-0c\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Please select the number that best describes the severity of your pain at this time. <\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_0\" name=\"fieldaa48ab-0c\"  value=\"0 - No Hurt\"><label for=\"field18297aa48ab-0c_0\">0 &#8211; No Hurt<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_1\" name=\"fieldaa48ab-0c\"  value=\"2 - Hurts Little Bit\"><label for=\"field18297aa48ab-0c_1\">2 &#8211; Hurts Little Bit<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_2\" name=\"fieldaa48ab-0c\"  value=\"4 - Hurts Little More\"><label for=\"field18297aa48ab-0c_2\">4 &#8211; Hurts Little More<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_3\" name=\"fieldaa48ab-0c\"  value=\"6 - Hurts Even More\"><label for=\"field18297aa48ab-0c_3\">6 &#8211; Hurts Even More<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_4\" name=\"fieldaa48ab-0c\"  value=\"8 - Hurts Whote Lot\"><label for=\"field18297aa48ab-0c_4\">8 &#8211; Hurts Whote Lot<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297aa48ab-0c_5\" name=\"fieldaa48ab-0c\"  value=\"10 - Hurts Worst\"><label for=\"field18297aa48ab-0c_5\">10 &#8211; Hurts Worst<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_ea48c3-3f > .kt-inside-inner-col,.kadence-column18297_ea48c3-3f > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_ea48c3-3f > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_ea48c3-3f > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_ea48c3-3f > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_ea48c3-3f > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_ea48c3-3f{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_ea48c3-3f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_ea48c3-3f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_ea48c3-3f\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297c1a139-f0 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18297c1a139-f0\">Use the text area below to describe where you are feeling the pain.<\/label><textarea name=\"fieldc1a139-f0\" id=\"field18297c1a139-f0\" rows=\"3\"  data-label=\"Use the text area below to describe where you are feeling the pain.\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_d79eec-c5 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_d79eec-c5 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_d79eec-c5 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18297_d79eec-c5 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_d79eec-c5 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_d79eec-c5 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_d79eec-c5 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_8e9698-de > .kt-inside-inner-col{display:flex;}.kadence-column18297_8e9698-de > .kt-inside-inner-col,.kadence-column18297_8e9698-de > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_8e9698-de > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_8e9698-de > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_8e9698-de > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_8e9698-de > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_8e9698-de{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_8e9698-de > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_8e9698-de > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_8e9698-de\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f, .wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f[data-kb-block=\"kb-adv-heading18297_98d4aa-6f\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f[data-kb-block=\"kb-adv-heading18297_98d4aa-6f\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_98d4aa-6f[data-kb-block=\"kb-adv-heading18297_98d4aa-6f\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_98d4aa-6f wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_98d4aa-6f\">Surgical History<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Please list any hospitalizations, surgeries, fractures, or major illnesses you have had<\/p>\n\n\n<style>.kb-row-layout-id18297_0695e5-ef > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_0695e5-ef > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_0695e5-ef > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-lg, 4rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18297_0695e5-ef > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_0695e5-ef > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_0695e5-ef > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_0695e5-ef alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col,.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_0c6b59-a8{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_0c6b59-a8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_0c6b59-a8\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297e59043-91 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18297e59043-91\">Type of Surgery\/Fracture\/Hospitalization <\/label><textarea name=\"fielde59043-91\" id=\"field18297e59043-91\" rows=\"3\"  data-label=\"Type of Surgery\/Fracture\/Hospitalization \" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_24a169-a3 > .kt-inside-inner-col,.kadence-column18297_24a169-a3 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_24a169-a3 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_24a169-a3 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_24a169-a3 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_24a169-a3 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_24a169-a3{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_24a169-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_24a169-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_24a169-a3\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829715ac26-1a wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1829715ac26-1a\">Year or Date<\/label><textarea name=\"field15ac26-1a\" id=\"field1829715ac26-1a\" rows=\"3\"  data-label=\"Year or Date\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_3c54e8-2d > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_3c54e8-2d > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_3c54e8-2d > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18297_3c54e8-2d > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_3c54e8-2d > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_3c54e8-2d > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_3c54e8-2d alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_440721-c1 > .kt-inside-inner-col{display:flex;}.kadence-column18297_440721-c1 > .kt-inside-inner-col,.kadence-column18297_440721-c1 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_440721-c1 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_440721-c1 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_440721-c1 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_440721-c1 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_440721-c1{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_440721-c1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_440721-c1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_440721-c1\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27, .wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27[data-kb-block=\"kb-adv-heading18297_ad9ded-27\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27[data-kb-block=\"kb-adv-heading18297_ad9ded-27\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_ad9ded-27[data-kb-block=\"kb-adv-heading18297_ad9ded-27\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_ad9ded-27 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_ad9ded-27\">Medication<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">List any medications you are currently taking (please include over-the-counter medications)<\/p>\n\n\n<style>.kb-row-layout-id18297_ee895b-f4 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_ee895b-f4 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_ee895b-f4 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18297_ee895b-f4 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_ee895b-f4 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_ee895b-f4 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_ee895b-f4 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_d5b09c-5a > .kt-inside-inner-col,.kadence-column18297_d5b09c-5a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_d5b09c-5a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_d5b09c-5a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_d5b09c-5a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_d5b09c-5a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_d5b09c-5a{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_d5b09c-5a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_d5b09c-5a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_d5b09c-5a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297ce83b2-bc wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18297ce83b2-bc\">Medication<\/label><textarea name=\"fieldce83b2-bc\" id=\"field18297ce83b2-bc\" rows=\"3\"  data-label=\"Medication\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_da56af-2f > .kt-inside-inner-col,.kadence-column18297_da56af-2f > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_da56af-2f > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_da56af-2f > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_da56af-2f > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_da56af-2f > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_da56af-2f{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_da56af-2f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_da56af-2f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_da56af-2f\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829716c4cb-2f wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1829716c4cb-2f\">Dosage<\/label><textarea name=\"field16c4cb-2f\" id=\"field1829716c4cb-2f\" rows=\"3\"  data-label=\"Dosage\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_268a18-35 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_268a18-35 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_268a18-35 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18297_268a18-35 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_268a18-35 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_268a18-35 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_268a18-35 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_df0a62-1c > .kt-inside-inner-col,.kadence-column18297_df0a62-1c > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_df0a62-1c > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_df0a62-1c > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_df0a62-1c > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_df0a62-1c > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_df0a62-1c{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_df0a62-1c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_df0a62-1c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_df0a62-1c\"><div class=\"kt-inside-inner-col\"><style>.kadence-column18297_5f009b-51 > .kt-inside-inner-col,.kadence-column18297_5f009b-51 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_5f009b-51 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_5f009b-51 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_5f009b-51 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_5f009b-51 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_5f009b-51{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_5f009b-51 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_5f009b-51 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_5f009b-51\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18297a38636-a3 wp-block-kadence-advanced-form-checkbox\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"cb18297a38636-a3\" data-type=\"checkbox\" data-required=\"no\" ><legend class=\"kb-adv-form-label\"><strong>Past Medical History:<\/strong> Please check any condition you have now or have had in the past<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_0\" name=\"fielda38636-a3[]\" value=\"Stroke \"><label for=\"field18297a38636-a3_0\">Stroke <\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_1\" name=\"fielda38636-a3[]\" value=\"Arthritis\"><label for=\"field18297a38636-a3_1\">Arthritis<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_2\" name=\"fielda38636-a3[]\" value=\"Hypertension\"><label for=\"field18297a38636-a3_2\">Hypertension<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_3\" name=\"fielda38636-a3[]\" value=\"Heart Disease\"><label for=\"field18297a38636-a3_3\">Heart Disease<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_4\" name=\"fielda38636-a3[]\" value=\"Diabetes\"><label for=\"field18297a38636-a3_4\">Diabetes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_5\" name=\"fielda38636-a3[]\" value=\"High Cholesterol\"><label for=\"field18297a38636-a3_5\">High Cholesterol<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18297a38636-a3_6\" name=\"fielda38636-a3[]\" value=\"Other conditions\"><label for=\"field18297a38636-a3_6\">Other conditions<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297bbcd2a-aa wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18297bbcd2a-aa\">Please specify<\/label><textarea name=\"fieldbbcd2a-aa\" id=\"field18297bbcd2a-aa\" rows=\"3\"  data-label=\"Please specify\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\"  data-conditional-rules=\"{&quot;container&quot;:&quot;.kb-field18297bbcd2a-aa&quot;,&quot;action&quot;:&quot;show&quot;,&quot;logic&quot;:&quot;or&quot;,&quot;rules&quot;:[{&quot;name&quot;:&quot;field18297a38636-a3&quot;,&quot;operator&quot;:&quot;is&quot;,&quot;value&quot;:&quot;Other conditions&quot;}]}\" ><\/textarea><\/div><\/div><\/div>\n<\/div><\/div>\n\n\n<style>.kadence-column18297_776b88-12 > .kt-inside-inner-col,.kadence-column18297_776b88-12 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_776b88-12 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_776b88-12 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_776b88-12 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_776b88-12 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_776b88-12{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_776b88-12 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_776b88-12 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_776b88-12\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1829709d0d6-02 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1829709d0d6-02\"><strong>Allergies:<\/strong> Please mention any known allergies<\/label><textarea name=\"field09d0d6-02\" id=\"field1829709d0d6-02\" rows=\"3\"  data-label=\"&lt;strong&gt;Allergies:&lt;\/strong&gt; Please mention any known allergies\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18297_bd0f2c-3a > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_bd0f2c-3a > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_bd0f2c-3a > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18297_bd0f2c-3a > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_bd0f2c-3a > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18297_bd0f2c-3a > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_bd0f2c-3a alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col,.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_a1d3ed-c9{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_a1d3ed-c9 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_a1d3ed-c9\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2, .wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2[data-kb-block=\"kb-adv-heading18297_e56b48-b2\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2[data-kb-block=\"kb-adv-heading18297_e56b48-b2\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_e56b48-b2[data-kb-block=\"kb-adv-heading18297_e56b48-b2\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_e56b48-b2 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_e56b48-b2\">HIPAA Notice &amp; Privacy Consent<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows our Notice of Privacy<br>Practices to detail how your PHI (protected health information) may be used for treatment, payment, and<br>operations. By signing below, you acknowledge:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">\u25cf You have reviewed our Privacy Notice.<br>\u25cf We may update our terms; you will be notified of changes at your next visit.<br>\u25cf You consent to the use of your PHI for treatment, billing, healthcare operations, and potentially anonymous use<br>in publications.<br>\u25cf You may revoke this consent in writing at any time (non-retroactive).<br>\u25cf The practice may condition treatment upon the signing of this consent.<\/p>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5, .wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5[data-kb-block=\"kb-adv-heading18297_0510c8-a5\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5[data-kb-block=\"kb-adv-heading18297_0510c8-a5\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_0510c8-a5[data-kb-block=\"kb-adv-heading18297_0510c8-a5\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_0510c8-a5 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_0510c8-a5\">Communication Preferences:<\/h3>\n\n\n<div class=\"kb-adv-form-field kb-field182974eb410-03 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb182974eb410-03\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">May we phone, email, or text you to confirm appointments?<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182974eb410-03_0\" name=\"field4eb410-03\"  value=\"Yes\"><label for=\"field182974eb410-03_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182974eb410-03_1\" name=\"field4eb410-03\"  value=\"No\"><label for=\"field182974eb410-03_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1829789547d-2a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1829789547d-2a\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">May we leave a message on your home or cell voicemail?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829789547d-2a_0\" name=\"field89547d-2a\"  value=\"Yes \"><label for=\"field1829789547d-2a_0\">Yes <\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829789547d-2a_1\" name=\"field89547d-2a\"  value=\"No\"><label for=\"field1829789547d-2a_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18297d095c2-8a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18297d095c2-8a\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">May we discuss your medical condition with family members?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297d095c2-8a_0\" name=\"fieldd095c2-8a\"  value=\"Yes\"><label for=\"field18297d095c2-8a_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297d095c2-8a_1\" name=\"fieldd095c2-8a\"  value=\"No\"><label for=\"field18297d095c2-8a_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_148124-5b > .kt-inside-inner-col{display:flex;}.kadence-column18297_148124-5b > .kt-inside-inner-col,.kadence-column18297_148124-5b > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_148124-5b > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_148124-5b > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_148124-5b > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_148124-5b > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_148124-5b{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_148124-5b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_148124-5b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_148124-5b\"><div class=\"kt-inside-inner-col\"><style>.kadence-column18297_617b2a-e0 > .kt-inside-inner-col{display:flex;}.kadence-column18297_617b2a-e0 > .kt-inside-inner-col,.kadence-column18297_617b2a-e0 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_617b2a-e0 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_617b2a-e0 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_617b2a-e0 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_617b2a-e0 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_617b2a-e0{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_617b2a-e0 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_617b2a-e0 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_617b2a-e0\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field1829718289_2d121e-05 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb1829718289_2d121e-05\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Benefit Assignment\/Release of Information<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"field18289_2d121e-05\" id=\"field1829718289_2d121e-05_0\" data-label=\"Benefit Assignment\/Release of Information\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field1829718289_2d121e-05_0\">I authorize my insurance provider (including Medicare and private insurers) to pay Sharma Rehabilitation Services PLLC<br>directly for medical services rendered. I also allow the release of necessary medical records to secure payment. A copy of<br>this agreement is as valid as the original<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18297c3088f-a6 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb18297c3088f-a6\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Authorization to Release Medical Records<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"fieldc3088f-a6\" id=\"field18297c3088f-a6_0\" data-label=\"Authorization to Release Medical Records\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field18297c3088f-a6_0\">I authorize Sharma Rehabilitation Services PLLC to request and obtain all medical records for myself and\/or my child<br>from any physician, hospital, or healthcare provider.<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18297635687-f8 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb18297635687-f8\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Financial Responsibility<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"field635687-f8\" id=\"field18297635687-f8_0\" data-label=\"Financial Responsibility\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field18297635687-f8_0\">I agree to pay all co-pays and any remaining balance not covered by my insurance<br>company.<\/label><\/div><\/fieldset><\/div>\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06, .wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06[data-kb-block=\"kb-adv-heading18297_b5d81c-06\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06[data-kb-block=\"kb-adv-heading18297_b5d81c-06\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18297_b5d81c-06[data-kb-block=\"kb-adv-heading18297_b5d81c-06\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18297_b5d81c-06 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18297_b5d81c-06\">General Consent for Care &amp; Treatment<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">By signing below, you authorize Bindu Sharma and the clinical team to perform necessary medical examinations, testing,<br>and treatments to evaluate and manage your condition.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Your Rights &amp; Agreement:<br>\u25cf <strong>Informed Choice:<\/strong> You have the right to discuss your treatment plan, including the purposes, risks, and<br>benefits of any recommended procedure, with your provider.<br><strong>\u25cf Scope of Consent:<\/strong> This consent is ongoing and applies to this facility and any satellite offices under common<br>ownership.<br>\u25cf<strong> Additional Procedures:<\/strong> If invasive or interventional procedures are required, a separate specific consent form<br>will be provided.<br>\u25cf<strong> Revocation: <\/strong>You may discontinue services or revoke this consent in writing at any time.<br><strong>\u25cf Acknowledgment:<\/strong> I have read this form and voluntarily request care. I understand that I am encouraged to<br>ask questions regarding any recommended tests or treatments.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">By checking the boxes below, I acknowledge that I have read and agree to each of the consent forms and agreements<br>listed above<\/p>\n\n\n<div class=\"kb-adv-form-field kb-field18297f8cd55-32 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18297f8cd55-32\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">HIPAA Notice &amp; Privacy Consent<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297f8cd55-32_0\" name=\"fieldf8cd55-32\"  value=\"Yes\"><label for=\"field18297f8cd55-32_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18297f8cd55-32_1\" name=\"fieldf8cd55-32\"  value=\"No\"><label for=\"field18297f8cd55-32_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field182975ba18c-2a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb182975ba18c-2a\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Benefit Assignment\/Release of Information<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182975ba18c-2a_0\" name=\"field5ba18c-2a\"  value=\"Yes\"><label for=\"field182975ba18c-2a_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182975ba18c-2a_1\" name=\"field5ba18c-2a\"  value=\"No\"><label for=\"field182975ba18c-2a_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field182972afeb0-f0 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb182972afeb0-f0\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Authorization to Release Medical Records<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182972afeb0-f0_0\" name=\"field2afeb0-f0\"  value=\"Yes\"><label for=\"field182972afeb0-f0_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field182972afeb0-f0_1\" name=\"field2afeb0-f0\"  value=\"No\"><label for=\"field182972afeb0-f0_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1829750a18e-bf wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1829750a18e-bf\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Financial Responsibility<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829750a18e-bf_0\" name=\"field50a18e-bf\"  value=\"Yes\"><label for=\"field1829750a18e-bf_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829750a18e-bf_1\" name=\"field50a18e-bf\"  value=\"No\"><label for=\"field1829750a18e-bf_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1829774021a-6d wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1829774021a-6d\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">General Consent for Care &amp; Treatment<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829774021a-6d_0\" name=\"field74021a-6d\"  value=\"Yes\"><label for=\"field1829774021a-6d_0\">Yes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1829774021a-6d_1\" name=\"field74021a-6d\"  value=\"No\"><label for=\"field1829774021a-6d_1\">No<\/label><\/div><\/fieldset><\/div>\n\n\n<p class=\"wp-block-paragraph\">By signing below, I acknowledge that I have read and agree to the terms of each authorization and consent form. My<br>selection serves as my digital signature for these specific agreements listed above.<\/p>\n\n\n<style>.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, calc(35% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)))minmax(0, calc(40% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)))minmax(0, calc(25% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)));}.kb-row-layout-id18297_bf73ae-3d > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18297_bf73ae-3d > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18297_bf73ae-3d alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18297_36410b-78 > .kt-inside-inner-col,.kadence-column18297_36410b-78 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_36410b-78 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_36410b-78 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_36410b-78 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_36410b-78 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_36410b-78{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_36410b-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_36410b-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_36410b-78\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297b594ce-f8 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297b594ce-f8\">This consent was signed by:<\/label><input name=\"fieldb594ce-f8\" id=\"field18297b594ce-f8\" data-label=\"This consent was signed by:\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_67c02f-0c > .kt-inside-inner-col,.kadence-column18297_67c02f-0c > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_67c02f-0c > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_67c02f-0c > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_67c02f-0c > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_67c02f-0c > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_67c02f-0c{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_67c02f-0c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_67c02f-0c > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_67c02f-0c\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18297daa178-1a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18297daa178-1a\">Patient\/Parent\/Legal Guardian Signature:<\/label><input name=\"fielddaa178-1a\" id=\"field18297daa178-1a\" data-label=\"Patient\/Parent\/Legal Guardian Signature:\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18297_4596a8-f4 > .kt-inside-inner-col,.kadence-column18297_4596a8-f4 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18297_4596a8-f4 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18297_4596a8-f4 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18297_4596a8-f4 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18297_4596a8-f4 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18297_4596a8-f4{position:relative;}@media all and (max-width: 1024px){.kadence-column18297_4596a8-f4 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18297_4596a8-f4 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18297_4596a8-f4\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field182970968d5-18 wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field182970968d5-18\">Date<\/label><input name=\"field0968d5-18\" id=\"field182970968d5-18\" data-label=\"Date\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n<\/div><\/div>\n\n\n<style>ul.menu .kb-submit-field .kb-btn1_default.kb-button{width:initial;}.kb-submit-field .kb-btn1_default.kb-button{text-transform:uppercase;}.kb-submit-field.kb-field1_default{justify-content:flex-start;}<\/style><div class=\"kb-adv-form-field kb-submit-field kb-field1_default wp-block-kadence-advanced-form-submit\"><button class=\"kb-button kt-button button kb-adv-form-submit-button kb-btn1_default kt-btn-size-small kt-btn-width-type-auto kb-btn-global-inherit kt-btn-has-text-true kt-btn-has-svg-false wp-block-button__link\" type=\"submit\"><span class=\"kt-btn-inner-text\">Submit Intake Form<\/span><\/button><\/div>\n<input type=\"hidden\" name=\"_kb_adv_form_post_id\" value=\"18297\"><input type=\"hidden\" name=\"action\" value=\"kb_process_advanced_form_submit\"><input type=\"hidden\" name=\"_kb_adv_form_id\" value=\"18297-cpt-id\"><\/form><\/div><\/div><\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-kadence-tab kt-tab-inner-content kt-inner-tab-2 kt-inner-tab18289_d98180-e8\"><div class=\"kt-tab-inner-content-inner\"><style>.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-lg, 3rem);padding-right:var(--global-kb-spacing-lg, 3rem);padding-bottom:var(--global-kb-spacing-lg, 3rem);padding-left:var(--global-kb-spacing-lg, 3rem);}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col,.kadence-column18289_4a75c5-03 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{background-color:var(--global-palette7, #EDF2F7);}.kadence-column18289_4a75c5-03 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_4a75c5-03{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-right:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);padding-left:var(--global-kb-spacing-sm, 1.5rem);flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_4a75c5-03 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_4a75c5-03\"><div class=\"kt-inside-inner-col\"><div class=\"wp-block-kadence-advanced-form wp-block-kadence-advanced-form18305-cpt-id kb-adv-form-label-style-normal kb-adv-form-input-size-standard kb-form-basic-style\"><form id=\"kb-adv-form-18305-cpt-id\" class=\"kb-advanced-form\" method=\"post\" data-kb-events=\"yes\">\n<style>.kadence-column18305_620b6c-1d > .kt-inside-inner-col{display:flex;}.kadence-column18305_620b6c-1d > .kt-inside-inner-col,.kadence-column18305_620b6c-1d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_620b6c-1d > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_620b6c-1d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_620b6c-1d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_620b6c-1d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_620b6c-1d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_620b6c-1d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_620b6c-1d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_620b6c-1d\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02, .wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02[data-kb-block=\"kb-adv-heading18305_646b9a-02\"]{font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02[data-kb-block=\"kb-adv-heading18305_646b9a-02\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_646b9a-02[data-kb-block=\"kb-adv-heading18305_646b9a-02\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<p class=\"kt-adv-heading18305_646b9a-02 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_646b9a-02\">Por favor provee la siguiente informaci\u00f3n, este formulario es confidencial y ser\u00e1 a\u00f1adido a sus antecedentes m\u00e9dicos con esta cl\u00ednica<\/p>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08, .wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08[data-kb-block=\"kb-adv-heading18305_49218d-08\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08[data-kb-block=\"kb-adv-heading18305_49218d-08\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_49218d-08[data-kb-block=\"kb-adv-heading18305_49218d-08\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18305_49218d-08 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_49218d-08\"><strong>Formulario de paciente nuevo<\/strong><\/h2>\n\n\n<style>.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18305_48cda8-4c > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_48cda8-4c > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_48cda8-4c alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_2a7684-0d > .kt-inside-inner-col,.kadence-column18305_2a7684-0d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_2a7684-0d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_2a7684-0d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_2a7684-0d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_2a7684-0d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_2a7684-0d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_2a7684-0d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_2a7684-0d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_2a7684-0d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305179e62-01 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305179e62-01\">Nombre<\/label><input name=\"field179e62-01\" id=\"field18305179e62-01\" data-label=\"Nombre\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_40976b-d6 > .kt-inside-inner-col,.kadence-column18305_40976b-d6 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_40976b-d6 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_40976b-d6 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_40976b-d6 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_40976b-d6 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_40976b-d6{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_40976b-d6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_40976b-d6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_40976b-d6\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305e3d284-a3 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305e3d284-a3\">Apellido<\/label><input name=\"fielde3d284-a3\" id=\"field18305e3d284-a3\" data-label=\"Apellido\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_fb9f92-07 > .kt-inside-inner-col,.kadence-column18305_fb9f92-07 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_fb9f92-07 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_fb9f92-07 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_fb9f92-07 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_fb9f92-07 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_fb9f92-07{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_fb9f92-07 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_fb9f92-07 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_fb9f92-07\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18305142eab-7c wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field18305142eab-7c\">Fecha de nacimiento<\/label><input name=\"field142eab-7c\" id=\"field18305142eab-7c\" data-label=\"Fecha de nacimiento\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18305_e4e27e-83 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e4e27e-83 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_e4e27e-83 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_ca0363-30 > .kt-inside-inner-col,.kadence-column18305_ca0363-30 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ca0363-30 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ca0363-30 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ca0363-30 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ca0363-30 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ca0363-30{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ca0363-30 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ca0363-30 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ca0363-30\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18305f8562c-27 wp-block-kadence-advanced-form-select\"><label class=\"kb-adv-form-label\" for=\"field18305f8562c-27\">Sexo<\/label><select  name=\"fieldf8562c-27\" id=\"field18305f8562c-27\" ><option value=\"\" disabled selected>Select<\/option><option value=\"Femenino\">Femenino<\/option><option value=\"Masculino\">Masculino<\/option><\/select><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_533bfe-68 > .kt-inside-inner-col,.kadence-column18305_533bfe-68 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_533bfe-68 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_533bfe-68 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_533bfe-68 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_533bfe-68 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_533bfe-68{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_533bfe-68 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_533bfe-68 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_533bfe-68\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183050c74d1-47 wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field183050c74d1-47\">Seguridad Social(SSN)<\/label><input name=\"field0c74d1-47\" id=\"field183050c74d1-47\" data-label=\"Seguridad Social(SSN)\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_704453-ca > .kt-inside-inner-col,.kadence-column18305_704453-ca > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_704453-ca > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_704453-ca > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_704453-ca > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_704453-ca > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_704453-ca{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_704453-ca > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_704453-ca > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_704453-ca\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830516c686-cc wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field1830516c686-cc\">Numero de telefono<\/label><input name=\"field16c686-cc\" id=\"field1830516c686-cc\" data-label=\"Numero de telefono\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_2d906d-54 > .kt-inside-inner-col,.kadence-column18305_2d906d-54 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_2d906d-54 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_2d906d-54 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_2d906d-54 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_2d906d-54 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_2d906d-54{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_2d906d-54 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_2d906d-54 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_2d906d-54\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305db344b-08 wp-block-kadence-advanced-form-email\"><label class=\"kb-adv-form-label\" for=\"field18305db344b-08\">Correo electronico<\/label><input name=\"fielddb344b-08\" id=\"field18305db344b-08\" data-label=\"Correo electronico\" type=\"email\" placeholder=\"\" value=\"\" data-type=\"email\" class=\"kb-field kb-email-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18305_c6f5c7-34 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_c6f5c7-34 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_c6f5c7-34 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col,.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ad3bb3-ca{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ad3bb3-ca > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ad3bb3-ca\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183054fdaa1-b5 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field183054fdaa1-b5\">Direccion<\/label><input name=\"field4fdaa1-b5\" id=\"field183054fdaa1-b5\" data-label=\"Direccion\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_66a8f1-43 > .kt-inside-inner-col,.kadence-column18305_66a8f1-43 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_66a8f1-43 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_66a8f1-43 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_66a8f1-43 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_66a8f1-43 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_66a8f1-43{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_66a8f1-43 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_66a8f1-43 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_66a8f1-43\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305b226a4-8a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305b226a4-8a\">Ciudad<\/label><input name=\"fieldb226a4-8a\" id=\"field18305b226a4-8a\" data-label=\"Ciudad\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_978bbf-bc > .kt-inside-inner-col,.kadence-column18305_978bbf-bc > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_978bbf-bc > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_978bbf-bc > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_978bbf-bc > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_978bbf-bc > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_978bbf-bc{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_978bbf-bc > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_978bbf-bc > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_978bbf-bc\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305fa0f61-07 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305fa0f61-07\">Estado<\/label><input name=\"fieldfa0f61-07\" id=\"field18305fa0f61-07\" data-label=\"Estado\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_33e04d-78 > .kt-inside-inner-col,.kadence-column18305_33e04d-78 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_33e04d-78 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_33e04d-78 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_33e04d-78 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_33e04d-78 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_33e04d-78{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_33e04d-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_33e04d-78 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_33e04d-78\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305154a6f-eb wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305154a6f-eb\">Zipcode<\/label><input name=\"field154a6f-eb\" id=\"field18305154a6f-eb\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}.kb-row-layout-id18305_e880d1-a9 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e880d1-a9 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_e880d1-a9 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_75c86c-7d > .kt-inside-inner-col,.kadence-column18305_75c86c-7d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_75c86c-7d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_75c86c-7d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_75c86c-7d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_75c86c-7d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_75c86c-7d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_75c86c-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_75c86c-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_75c86c-7d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830551dd3f-ee wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830551dd3f-ee\">Marital status<\/label><input name=\"field51dd3f-ee\" id=\"field1830551dd3f-ee\" data-label=\"Marital status\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_75304e-4a > .kt-inside-inner-col,.kadence-column18305_75304e-4a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_75304e-4a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_75304e-4a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_75304e-4a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_75304e-4a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_75304e-4a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_75304e-4a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_75304e-4a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_75304e-4a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305273cb8-7f wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305273cb8-7f\">Marital status<\/label><input name=\"field273cb8-7f\" id=\"field18305273cb8-7f\" data-label=\"Marital status\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_b9800d-44 > .kt-inside-inner-col,.kadence-column18305_b9800d-44 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_b9800d-44 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_b9800d-44 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_b9800d-44 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_b9800d-44 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_b9800d-44{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_b9800d-44 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_b9800d-44 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_b9800d-44\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183057a0172-b9 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field183057a0172-b9\">Parentesco\/relacion<\/label><input name=\"field7a0172-b9\" id=\"field183057a0172-b9\" data-label=\"Parentesco\/relacion\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_0f3da0-16 > .kt-inside-inner-col,.kadence-column18305_0f3da0-16 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_0f3da0-16 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_0f3da0-16 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_0f3da0-16 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_0f3da0-16 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_0f3da0-16{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_0f3da0-16 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_0f3da0-16 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_0f3da0-16\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183052316cd-88 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field183052316cd-88\">Numero de telefono<\/label><input name=\"field2316cd-88\" id=\"field183052316cd-88\" data-label=\"Numero de telefono\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col{display:flex;}.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col,.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_d5e9c6-3e{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_d5e9c6-3e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_d5e9c6-3e\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98, .wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98[data-kb-block=\"kb-adv-heading18305_6264c9-98\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98[data-kb-block=\"kb-adv-heading18305_6264c9-98\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_6264c9-98[data-kb-block=\"kb-adv-heading18305_6264c9-98\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18305_6264c9-98 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_6264c9-98\"><strong>Informaci\u00f3n del seguro<\/strong><\/h2>\n\n\n<style>.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}.kb-row-layout-id18305_e40dae-66 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap{grid-template-columns:repeat(4, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_e40dae-66 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_e40dae-66 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_a17d6d-35 > .kt-inside-inner-col,.kadence-column18305_a17d6d-35 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_a17d6d-35 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_a17d6d-35 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_a17d6d-35 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_a17d6d-35 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_a17d6d-35{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_a17d6d-35 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_a17d6d-35 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_a17d6d-35\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183055518b2-16 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field183055518b2-16\">Nombre del seguro<\/label><input name=\"field5518b2-16\" id=\"field183055518b2-16\" data-label=\"Nombre del seguro\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col,.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_5bd1c0-ef{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_5bd1c0-ef > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_5bd1c0-ef\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305946527-04 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305946527-04\">Numero de miembro<\/label><input name=\"field946527-04\" id=\"field18305946527-04\" data-label=\"Numero de miembro\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_681c4b-61 > .kt-inside-inner-col,.kadence-column18305_681c4b-61 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_681c4b-61 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_681c4b-61 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_681c4b-61 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_681c4b-61 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_681c4b-61{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_681c4b-61 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_681c4b-61 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_681c4b-61\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830548750b-8e wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830548750b-8e\">Fecha de nacimiento<\/label><input name=\"field48750b-8e\" id=\"field1830548750b-8e\" data-label=\"Fecha de nacimiento\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_48028a-aa > .kt-inside-inner-col,.kadence-column18305_48028a-aa > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_48028a-aa > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_48028a-aa > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_48028a-aa > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_48028a-aa > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_48028a-aa{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_48028a-aa > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_48028a-aa > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_48028a-aa\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183051a0fff-2b wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field183051a0fff-2b\">Nombre<\/label><input name=\"field1a0fff-2b\" id=\"field183051a0fff-2b\" data-label=\"Nombre\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18305_36e9e0-2d > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_36e9e0-2d > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_36e9e0-2d alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_be65b4-72 > .kt-inside-inner-col,.kadence-column18305_be65b4-72 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_be65b4-72 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_be65b4-72 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_be65b4-72 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_be65b4-72 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_be65b4-72{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_be65b4-72 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_be65b4-72 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_be65b4-72\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18305a29fcb-1f wp-block-kadence-advanced-form-select\"><label class=\"kb-adv-form-label\" for=\"field18305a29fcb-1f\">Tienes un seguro secundario?\u00a0<\/label><select  name=\"fielda29fcb-1f\" id=\"field18305a29fcb-1f\" ><option value=\"\" disabled selected>Select<\/option><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><\/select><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col,.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_5a2db1-d3{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_5a2db1-d3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_5a2db1-d3\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830587ae31-ef wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830587ae31-ef\">Nombre del seguro<\/label><input name=\"field87ae31-ef\" id=\"field1830587ae31-ef\" data-label=\"Nombre del seguro\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_b37694-b2 > .kt-inside-inner-col,.kadence-column18305_b37694-b2 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_b37694-b2 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_b37694-b2 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_b37694-b2 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_b37694-b2 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_b37694-b2{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_b37694-b2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_b37694-b2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_b37694-b2\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305503c49-4b wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field18305503c49-4b\">Numero de miembro<\/label><input name=\"field503c49-4b\" id=\"field18305503c49-4b\" data-label=\"Numero de miembro\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_34e07f-c6 > .kt-inside-inner-col,.kadence-column18305_34e07f-c6 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_34e07f-c6 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_34e07f-c6 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_34e07f-c6 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_34e07f-c6 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_34e07f-c6{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_34e07f-c6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_34e07f-c6 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_34e07f-c6\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305b9615d-5b wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field18305b9615d-5b\">Nombre<\/label><input name=\"fieldb9615d-5b\" id=\"field18305b9615d-5b\" data-label=\"Nombre\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_550a01-c9 > .kt-inside-inner-col{display:flex;}.kadence-column18305_550a01-c9 > .kt-inside-inner-col,.kadence-column18305_550a01-c9 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_550a01-c9 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_550a01-c9 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_550a01-c9 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_550a01-c9 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_550a01-c9{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_550a01-c9 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_550a01-c9 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_550a01-c9\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4, .wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4[data-kb-block=\"kb-adv-heading18305_325fc4-d4\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4[data-kb-block=\"kb-adv-heading18305_325fc4-d4\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_325fc4-d4[data-kb-block=\"kb-adv-heading18305_325fc4-d4\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18305_325fc4-d4 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_325fc4-d4\"><strong>SOLO Compensaci\u00f3n de trabajo (WC)\/Accidentes de auto (NO-FAULT)<\/strong><\/h2>\n\n\n<style>.kb-row-layout-id18305_ed987b-a1 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_ed987b-a1 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_ed987b-a1 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18305_ed987b-a1 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_ed987b-a1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_ed987b-a1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_ed987b-a1 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col,.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_43d6d6-f2{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_43d6d6-f2 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_43d6d6-f2\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305ed6a80-2b wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305ed6a80-2b\">Nombre del empleador<\/label><input name=\"fielded6a80-2b\" id=\"field18305ed6a80-2b\" data-label=\"Nombre del empleador\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_58b0cf-14 > .kt-inside-inner-col,.kadence-column18305_58b0cf-14 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_58b0cf-14 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_58b0cf-14 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_58b0cf-14 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_58b0cf-14 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_58b0cf-14{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_58b0cf-14 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_58b0cf-14 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_58b0cf-14\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305495cbd-5e wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18305495cbd-5e\">Numero de telefono<\/label><input name=\"field495cbd-5e\" id=\"field18305495cbd-5e\" data-label=\"Numero de telefono\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18305_de654d-c1 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_de654d-c1 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_de654d-c1 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col,.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_7d6b4c-90{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_7d6b4c-90 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_7d6b4c-90\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305a4301f-57 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305a4301f-57\">Direccion<\/label><input name=\"fielda4301f-57\" id=\"field18305a4301f-57\" data-label=\"Direccion\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_1f89d2-7d > .kt-inside-inner-col,.kadence-column18305_1f89d2-7d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_1f89d2-7d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_1f89d2-7d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_1f89d2-7d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_1f89d2-7d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_1f89d2-7d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_1f89d2-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_1f89d2-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_1f89d2-7d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305d663ce-36 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305d663ce-36\">Ciudad<\/label><input name=\"fieldd663ce-36\" id=\"field18305d663ce-36\" data-label=\"Ciudad\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_3926e4-48 > .kt-inside-inner-col,.kadence-column18305_3926e4-48 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_3926e4-48 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_3926e4-48 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_3926e4-48 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_3926e4-48 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_3926e4-48{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_3926e4-48 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_3926e4-48 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_3926e4-48\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305a5514b-92 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305a5514b-92\">Estado<\/label><input name=\"fielda5514b-92\" id=\"field18305a5514b-92\" data-label=\"Estado\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_f5f471-39 > .kt-inside-inner-col,.kadence-column18305_f5f471-39 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_f5f471-39 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_f5f471-39 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_f5f471-39 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_f5f471-39 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_f5f471-39{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_f5f471-39 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_f5f471-39 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_f5f471-39\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183059c4707-50 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field183059c4707-50\">Zipcode<\/label><input name=\"field9c4707-50\" id=\"field183059c4707-50\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18305_201175-81 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_201175-81 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_201175-81 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_0cb56b-4f > .kt-inside-inner-col,.kadence-column18305_0cb56b-4f > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_0cb56b-4f > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_0cb56b-4f > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_0cb56b-4f > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_0cb56b-4f > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_0cb56b-4f{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_0cb56b-4f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_0cb56b-4f > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_0cb56b-4f\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305c443a4-ea wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field18305c443a4-ea\">N\u00famero de reclamo<\/label><input name=\"fieldc443a4-ea\" id=\"field18305c443a4-ea\" data-label=\"N\u00famero de reclamo\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_20663c-e1 > .kt-inside-inner-col,.kadence-column18305_20663c-e1 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_20663c-e1 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_20663c-e1 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_20663c-e1 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_20663c-e1 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_20663c-e1{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_20663c-e1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_20663c-e1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_20663c-e1\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830528d752-d2 wp-block-kadence-advanced-form-number\"><label class=\"kb-adv-form-label\" for=\"field1830528d752-d2\">WCB #<\/label><input name=\"field28d752-d2\" id=\"field1830528d752-d2\" data-label=\"WCB #\" type=\"number\" placeholder=\"\" value=\"\" data-type=\"number\" class=\"kb-field kb-number-field\" data-required=\"no\"  \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_ed5883-8a > .kt-inside-inner-col,.kadence-column18305_ed5883-8a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ed5883-8a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ed5883-8a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ed5883-8a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ed5883-8a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ed5883-8a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ed5883-8a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ed5883-8a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ed5883-8a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305ba08ab-af wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305ba08ab-af\">Carrier Case #<\/label><input name=\"fieldba08ab-af\" id=\"field18305ba08ab-af\" data-label=\"Carrier Case #\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18305_bed64e-6c > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_bed64e-6c > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_bed64e-6c alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col,.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_1bf1ec-8b{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_1bf1ec-8b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_1bf1ec-8b\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305491ead-07 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305491ead-07\">Adjuster Name<em> (persona que lleva el caso, diferente al abogado)<\/em><\/label><input name=\"field491ead-07\" id=\"field18305491ead-07\" data-label=\"Adjuster Name&lt;em&gt; (persona que lleva el caso, diferente al abogado)&lt;\/em&gt;\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_ac2beb-73 > .kt-inside-inner-col,.kadence-column18305_ac2beb-73 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ac2beb-73 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ac2beb-73 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ac2beb-73 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ac2beb-73 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ac2beb-73{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ac2beb-73 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ac2beb-73 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ac2beb-73\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305677993-6e wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18305677993-6e\">Numero de telefono<\/label><input name=\"field677993-6e\" id=\"field18305677993-6e\" data-label=\"Numero de telefono\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_271143-90 > .kt-inside-inner-col,.kadence-column18305_271143-90 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_271143-90 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_271143-90 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_271143-90 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_271143-90 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_271143-90{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_271143-90 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_271143-90 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_271143-90\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305d4b411-24 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18305d4b411-24\">Numero de Fax<\/label><input name=\"fieldd4b411-24\" id=\"field18305d4b411-24\" data-label=\"Numero de Fax\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18305_647da1-ba > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_647da1-ba > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_647da1-ba alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_c8e84f-5b > .kt-inside-inner-col,.kadence-column18305_c8e84f-5b > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_c8e84f-5b > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_c8e84f-5b > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_c8e84f-5b > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_c8e84f-5b > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_c8e84f-5b{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_c8e84f-5b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_c8e84f-5b > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_c8e84f-5b\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305fe302a-9b wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305fe302a-9b\">Nombre del abogado<\/label><input name=\"fieldfe302a-9b\" id=\"field18305fe302a-9b\" data-label=\"Nombre del abogado\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col,.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ec9ee7-0a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ec9ee7-0a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ec9ee7-0a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305750fef-5b wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field18305750fef-5b\">Numero de telefono<\/label><input name=\"field750fef-5b\" id=\"field18305750fef-5b\" data-label=\"Numero de telefono\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col,.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_cbd5c0-91{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_cbd5c0-91 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_cbd5c0-91\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830585bc20-71 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field1830585bc20-71\">Numero de Fax<\/label><input name=\"field85bc20-71\" id=\"field1830585bc20-71\" data-label=\"Numero de Fax\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col{display:flex;}.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col,.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_5a4bd0-e8{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_5a4bd0-e8 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_5a4bd0-e8\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92, .wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92[data-kb-block=\"kb-adv-heading18305_24b47c-92\"]{font-size:24px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92[data-kb-block=\"kb-adv-heading18305_24b47c-92\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_24b47c-92[data-kb-block=\"kb-adv-heading18305_24b47c-92\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18305_24b47c-92 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_24b47c-92\"><strong>M\u00e9dico primario o m\u00e9dico que lo refiri\u00f3<\/strong><\/h2>\n\n\n<style>.kb-row-layout-id18305_5dadb6-aa > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_5dadb6-aa > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_5dadb6-aa > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18305_5dadb6-aa > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_5dadb6-aa > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_5dadb6-aa > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_5dadb6-aa alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_712414-43 > .kt-inside-inner-col,.kadence-column18305_712414-43 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_712414-43 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_712414-43 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_712414-43 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_712414-43 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_712414-43{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_712414-43 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_712414-43 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_712414-43\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830505e7b2-d8 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830505e7b2-d8\">Nombre<\/label><input name=\"field05e7b2-d8\" id=\"field1830505e7b2-d8\" data-label=\"Nombre\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_261cd8-b4 > .kt-inside-inner-col,.kadence-column18305_261cd8-b4 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_261cd8-b4 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_261cd8-b4 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_261cd8-b4 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_261cd8-b4 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_261cd8-b4{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_261cd8-b4 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_261cd8-b4 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_261cd8-b4\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field183058e9729-a5 wp-block-kadence-advanced-form-telephone\"><label class=\"kb-adv-form-label\" for=\"field183058e9729-a5\">Nombre<\/label><input name=\"field8e9729-a5\" id=\"field183058e9729-a5\" data-label=\"Nombre\" type=\"tel\" placeholder=\"\" value=\"\" data-type=\"tel\" class=\"kb-field kb-tel-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}.kb-row-layout-id18305_090ce7-d3 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr) minmax(0, 1fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_090ce7-d3 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_090ce7-d3 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-4-columns kt-row-layout-left-forty kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_56f44f-12 > .kt-inside-inner-col,.kadence-column18305_56f44f-12 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_56f44f-12 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_56f44f-12 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_56f44f-12 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_56f44f-12 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_56f44f-12{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_56f44f-12 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_56f44f-12 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_56f44f-12\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305c8ee18-f1 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305c8ee18-f1\">Direccion<\/label><input name=\"fieldc8ee18-f1\" id=\"field18305c8ee18-f1\" data-label=\"Direccion\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_5c1aed-bf > .kt-inside-inner-col,.kadence-column18305_5c1aed-bf > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_5c1aed-bf > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_5c1aed-bf > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_5c1aed-bf > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_5c1aed-bf > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_5c1aed-bf{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_5c1aed-bf > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_5c1aed-bf > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_5c1aed-bf\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305c7d90d-16 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305c7d90d-16\">Ciudad<\/label><input name=\"fieldc7d90d-16\" id=\"field18305c7d90d-16\" data-label=\"Ciudad\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_c89c17-8d > .kt-inside-inner-col,.kadence-column18305_c89c17-8d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_c89c17-8d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_c89c17-8d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_c89c17-8d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_c89c17-8d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_c89c17-8d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_c89c17-8d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_c89c17-8d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_c89c17-8d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830564c68a-b5 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830564c68a-b5\">Estado<\/label><input name=\"field64c68a-b5\" id=\"field1830564c68a-b5\" data-label=\"Estado\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_3b1685-a3 > .kt-inside-inner-col,.kadence-column18305_3b1685-a3 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_3b1685-a3 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_3b1685-a3 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_3b1685-a3 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_3b1685-a3 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_3b1685-a3{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_3b1685-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_3b1685-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_3b1685-a3\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830531f17c-7a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field1830531f17c-7a\">Zipcode<\/label><input name=\"field31f17c-7a\" id=\"field1830531f17c-7a\" data-label=\"Zipcode\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}.kb-row-layout-id18305_00755d-8c > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_00755d-8c > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_00755d-8c alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_af7120-29 > .kt-inside-inner-col,.kadence-column18305_af7120-29 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_af7120-29 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_af7120-29 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_af7120-29 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_af7120-29 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_af7120-29{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_af7120-29 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_af7120-29 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_af7120-29\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18305546709-c4 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"rb18305546709-c4\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Tienes un marcapasos implantado?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305546709-c4_0\" name=\"field546709-c4\"  value=\"Si\"><label for=\"field18305546709-c4_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305546709-c4_1\" name=\"field546709-c4\"  value=\"No\"><label for=\"field18305546709-c4_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col,.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_bcfa7d-37{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_bcfa7d-37 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_bcfa7d-37\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18305aabfb7-ba wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"rb18305aabfb7-ba\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Has tomado terapia f\u00edsica este a\u00f1o? <\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aabfb7-ba_0\" name=\"fieldaabfb7-ba\"  value=\"Si\"><label for=\"field18305aabfb7-ba_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aabfb7-ba_1\" name=\"fieldaabfb7-ba\"  value=\"No\"><label for=\"field18305aabfb7-ba_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_a38408-5a > .kt-inside-inner-col,.kadence-column18305_a38408-5a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_a38408-5a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_a38408-5a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_a38408-5a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_a38408-5a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_a38408-5a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_a38408-5a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_a38408-5a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_a38408-5a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field18305648669-74 wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field18305648669-74\">Si es as\u00ed, cu\u00e1ndo?<\/label><input name=\"field648669-74\" id=\"field18305648669-74\" data-label=\"Si es as\u00ed, cu\u00e1ndo?\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\"  data-conditional-rules=\"{&quot;container&quot;:&quot;.kb-field18305648669-74&quot;,&quot;action&quot;:&quot;show&quot;,&quot;logic&quot;:&quot;or&quot;,&quot;rules&quot;:[{&quot;name&quot;:&quot;field18305aabfb7-ba&quot;,&quot;operator&quot;:&quot;is&quot;,&quot;value&quot;:&quot;Si&quot;}]}\" \/><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6, .wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6[data-kb-block=\"kb-adv-heading18305_16325a-f6\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6[data-kb-block=\"kb-adv-heading18305_16325a-f6\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_16325a-f6[data-kb-block=\"kb-adv-heading18305_16325a-f6\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_16325a-f6 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_16325a-f6\">Si es as\u00ed, cu\u00e1ndo?<\/h3>\n\n\n<style>.kb-row-layout-id18305_1de7a6-73 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_1de7a6-73 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_1de7a6-73 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:repeat(2, minmax(0, 1fr));}.kb-row-layout-id18305_1de7a6-73 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_1de7a6-73 > .kt-row-column-wrap{grid-template-columns:repeat(2, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_1de7a6-73 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_1de7a6-73 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_bb6c57-59 > .kt-inside-inner-col,.kadence-column18305_bb6c57-59 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_bb6c57-59 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_bb6c57-59 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_bb6c57-59 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_bb6c57-59 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_bb6c57-59{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_bb6c57-59 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_bb6c57-59 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_bb6c57-59\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18305aa48ab-0c wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18305aa48ab-0c\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Por favor haga un c\u00edrculo en la imagen\/numero que describa que tan severo es el dolor que siente (en la imagen de la izquierda).<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_0\" name=\"fieldaa48ab-0c\"  value=\"0 - No Hurt\"><label for=\"field18305aa48ab-0c_0\">0 &#8211; No Hurt<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_1\" name=\"fieldaa48ab-0c\"  value=\"2 - Hurts Little Bit\"><label for=\"field18305aa48ab-0c_1\">2 &#8211; Hurts Little Bit<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_2\" name=\"fieldaa48ab-0c\"  value=\"4 - Hurts Little More\"><label for=\"field18305aa48ab-0c_2\">4 &#8211; Hurts Little More<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_3\" name=\"fieldaa48ab-0c\"  value=\"6 - Hurts Even More\"><label for=\"field18305aa48ab-0c_3\">6 &#8211; Hurts Even More<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_4\" name=\"fieldaa48ab-0c\"  value=\"8 - Hurts Whote Lot\"><label for=\"field18305aa48ab-0c_4\">8 &#8211; Hurts Whote Lot<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305aa48ab-0c_5\" name=\"fieldaa48ab-0c\"  value=\"10 - Hurts Worst\"><label for=\"field18305aa48ab-0c_5\">10 &#8211; Hurts Worst<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_069e89-57 > .kt-inside-inner-col,.kadence-column18305_069e89-57 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_069e89-57 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_069e89-57 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_069e89-57 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_069e89-57 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_069e89-57{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_069e89-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_069e89-57 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_069e89-57\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305c1a139-f0 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18305c1a139-f0\">Tambi\u00e9n marque un c\u00edrculo en la parte del cuerpo en la que desea recibir terapia (en la imagen de la derecha)<\/label><textarea name=\"fieldc1a139-f0\" id=\"field18305c1a139-f0\" rows=\"3\"  data-label=\"Tambi\u00e9n marque un c\u00edrculo en la parte del cuerpo en la que desea recibir terapia (en la imagen de la derecha)\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_54abc9-d6 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_54abc9-d6 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_54abc9-d6 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18305_54abc9-d6 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_54abc9-d6 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_54abc9-d6 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_54abc9-d6 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col{display:flex;}.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col,.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_ef66d0-f0{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_ef66d0-f0 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_ef66d0-f0\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95, .wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95[data-kb-block=\"kb-adv-heading18305_5fff6c-95\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95[data-kb-block=\"kb-adv-heading18305_5fff6c-95\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_5fff6c-95[data-kb-block=\"kb-adv-heading18305_5fff6c-95\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_5fff6c-95 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_5fff6c-95\"><strong>Historia cl\u00ednica (cirug\u00edas)<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Por favor enliste cualquier hospitalizaci\u00f3n, cirug\u00eda, fractura o enfermedad de gravedad\u00a0 que haya tenido.<\/p>\n\n\n<style>.kb-row-layout-id18305_ed4965-d3 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_ed4965-d3 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_ed4965-d3 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-lg, 4rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18305_ed4965-d3 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_ed4965-d3 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_ed4965-d3 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_ed4965-d3 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_419f95-89 > .kt-inside-inner-col,.kadence-column18305_419f95-89 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_419f95-89 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_419f95-89 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_419f95-89 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_419f95-89 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_419f95-89{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_419f95-89 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_419f95-89 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_419f95-89\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305e59043-91 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18305e59043-91\">Tipo de cirug\u00eda\/fractura\/hospitalizaci\u00f3n<\/label><textarea name=\"fielde59043-91\" id=\"field18305e59043-91\" rows=\"3\"  data-label=\"Tipo de cirug\u00eda\/fractura\/hospitalizaci\u00f3n\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_20800b-77 > .kt-inside-inner-col,.kadence-column18305_20800b-77 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_20800b-77 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_20800b-77 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_20800b-77 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_20800b-77 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_20800b-77{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_20800b-77 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_20800b-77 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_20800b-77\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830515ac26-1a wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1830515ac26-1a\">A\u00f1o o fecha<\/label><textarea name=\"field15ac26-1a\" id=\"field1830515ac26-1a\" rows=\"3\"  data-label=\"A\u00f1o o fecha\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_649ee8-53 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_649ee8-53 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_649ee8-53 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18305_649ee8-53 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_649ee8-53 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_649ee8-53 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_649ee8-53 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_b9f626-6e > .kt-inside-inner-col{display:flex;}.kadence-column18305_b9f626-6e > .kt-inside-inner-col,.kadence-column18305_b9f626-6e > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_b9f626-6e > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_b9f626-6e > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_b9f626-6e > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_b9f626-6e > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_b9f626-6e{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_b9f626-6e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_b9f626-6e > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_b9f626-6e\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5, .wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5[data-kb-block=\"kb-adv-heading18305_1ad7a8-a5\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5[data-kb-block=\"kb-adv-heading18305_1ad7a8-a5\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_1ad7a8-a5[data-kb-block=\"kb-adv-heading18305_1ad7a8-a5\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_1ad7a8-a5 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_1ad7a8-a5\"><strong>Medicamentos<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Medicamento<\/p>\n\n\n<style>.kb-row-layout-id18305_cbc877-57 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_cbc877-57 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_cbc877-57 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}.kb-row-layout-id18305_cbc877-57 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_cbc877-57 > .kt-row-column-wrap{grid-template-columns:minmax(0, 2fr) minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_cbc877-57 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_cbc877-57 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-left-golden kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_885d17-6a > .kt-inside-inner-col,.kadence-column18305_885d17-6a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_885d17-6a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_885d17-6a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_885d17-6a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_885d17-6a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_885d17-6a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_885d17-6a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_885d17-6a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_885d17-6a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305ce83b2-bc wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18305ce83b2-bc\">Por favor, enliste los medicamentos que est\u00e1 tomando actualmente (incluya medicamentos over-the-counter (gen\u00e9ricos)):<\/label><textarea name=\"fieldce83b2-bc\" id=\"field18305ce83b2-bc\" rows=\"3\"  data-label=\"Por favor, enliste los medicamentos que est\u00e1 tomando actualmente (incluya medicamentos over-the-counter (gen\u00e9ricos)):\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_c3060c-a1 > .kt-inside-inner-col,.kadence-column18305_c3060c-a1 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_c3060c-a1 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_c3060c-a1 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_c3060c-a1 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_c3060c-a1 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_c3060c-a1{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_c3060c-a1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_c3060c-a1 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_c3060c-a1\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830516c4cb-2f wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1830516c4cb-2f\">Dosis<\/label><textarea name=\"field16c4cb-2f\" id=\"field1830516c4cb-2f\" rows=\"3\"  data-label=\"Dosis\" placeholder=\"Please list\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_4bd4f6-3f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_4bd4f6-3f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_4bd4f6-3f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18305_4bd4f6-3f > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_4bd4f6-3f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_4bd4f6-3f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_4bd4f6-3f alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_19fd85-fe > .kt-inside-inner-col,.kadence-column18305_19fd85-fe > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_19fd85-fe > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_19fd85-fe > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_19fd85-fe > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_19fd85-fe > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_19fd85-fe{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_19fd85-fe > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_19fd85-fe > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_19fd85-fe\"><div class=\"kt-inside-inner-col\"><style>.kadence-column18305_90784f-a3 > .kt-inside-inner-col,.kadence-column18305_90784f-a3 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_90784f-a3 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_90784f-a3 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_90784f-a3 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_90784f-a3 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_90784f-a3{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_90784f-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_90784f-a3 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_90784f-a3\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field18305a38636-a3 wp-block-kadence-advanced-form-checkbox\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"cb18305a38636-a3\" data-type=\"checkbox\" data-required=\"no\" ><legend class=\"kb-adv-form-label\"><strong><strong>Medicamentos<\/strong>:<\/strong> Por favor seleccione la casilla de la condici\u00f3n que tiene o tuvo en el pasado<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_0\" name=\"fielda38636-a3[]\" value=\"Derrame\"><label for=\"field18305a38636-a3_0\">Derrame<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_1\" name=\"fielda38636-a3[]\" value=\"Artritis\"><label for=\"field18305a38636-a3_1\">Artritis<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_2\" name=\"fielda38636-a3[]\" value=\"Hipertension\"><label for=\"field18305a38636-a3_2\">Hipertension<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_3\" name=\"fielda38636-a3[]\" value=\"Enfermedad cardiovascular\"><label for=\"field18305a38636-a3_3\">Enfermedad cardiovascular<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_4\" name=\"fielda38636-a3[]\" value=\"Diabetes\"><label for=\"field18305a38636-a3_4\">Diabetes<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_5\" name=\"fielda38636-a3[]\" value=\"Colesterol alto\"><label for=\"field18305a38636-a3_5\">Colesterol alto<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-checkbox-style\" type=\"checkbox\"  id=\"field18305a38636-a3_6\" name=\"fielda38636-a3[]\" value=\"Otra condicion\"><label for=\"field18305a38636-a3_6\">Otra condicion<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305bbcd2a-aa wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field18305bbcd2a-aa\">Please specify<\/label><textarea name=\"fieldbbcd2a-aa\" id=\"field18305bbcd2a-aa\" rows=\"3\"  data-label=\"Please specify\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\"  data-conditional-rules=\"{&quot;container&quot;:&quot;.kb-field18305bbcd2a-aa&quot;,&quot;action&quot;:&quot;show&quot;,&quot;logic&quot;:&quot;or&quot;,&quot;rules&quot;:[{&quot;name&quot;:&quot;field18305a38636-a3&quot;,&quot;operator&quot;:&quot;is&quot;,&quot;value&quot;:&quot;Other conditions&quot;}]}\" ><\/textarea><\/div><\/div><\/div>\n<\/div><\/div>\n\n\n<style>.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col,.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_dc2fd8-ee{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_dc2fd8-ee > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_dc2fd8-ee\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field1830509d0d6-02 wp-block-kadence-advanced-form-textarea\"><label class=\"kb-adv-form-label\" for=\"field1830509d0d6-02\"><strong>Alergias:<\/strong><em> <\/em>por favor mencione cualquier alergia conocida\u00a0<\/label><textarea name=\"field09d0d6-02\" id=\"field1830509d0d6-02\" rows=\"3\"  data-label=\"&lt;strong&gt;Alergias:&lt;\/strong&gt;&lt;em&gt; &lt;\/em&gt;por favor mencione cualquier alergia conocida\u00a0\" placeholder=\"\" data-type=\"textarea\" class=\"kb-field kb-textarea-field\" data-required=\"no\" ><\/textarea><\/div><\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18305_565364-69 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_565364-69 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_565364-69 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18305_565364-69 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_565364-69 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18305_565364-69 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_565364-69 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_9f90ff-45 > .kt-inside-inner-col,.kadence-column18305_9f90ff-45 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_9f90ff-45 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_9f90ff-45 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_9f90ff-45 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_9f90ff-45 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_9f90ff-45{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_9f90ff-45 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_9f90ff-45 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_9f90ff-45\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56, .wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56[data-kb-block=\"kb-adv-heading18305_d552c5-56\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56[data-kb-block=\"kb-adv-heading18305_d552c5-56\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_d552c5-56[data-kb-block=\"kb-adv-heading18305_d552c5-56\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_d552c5-56 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_d552c5-56\"><strong>Aviso de HIPAA y consentimiento de privacidad<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">La ley HIPAA (Ley de Portabilidad y Responsabilidad del Seguro M\u00e9dico de 1996) permite que nuestro Aviso de Pr\u00e1cticas de Privacidad detalle c\u00f3mo se puede utilizar su PHI (informaci\u00f3n m\u00e9dica protegida) para tratamientos, pagos y operaciones. Al firmar a continuaci\u00f3n, usted reconoce:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">&#8211; Usted ha revisado el Aviso de Privacidad.<\/p>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3, .wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3[data-kb-block=\"kb-adv-heading18305_d473f4-b3\"]{font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3[data-kb-block=\"kb-adv-heading18305_d473f4-b3\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_d473f4-b3[data-kb-block=\"kb-adv-heading18305_d473f4-b3\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<p class=\"kt-adv-heading18305_d473f4-b3 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_d473f4-b3\">&#8211; Podemos actualizar nuestros t\u00e9rminos; se le notificar\u00e1 de los cambios en su pr\u00f3xima visita.<br>&#8211; Usted consiente el uso de su PHI para tratamiento, facturaci\u00f3n, operaciones de atenci\u00f3n m\u00e9dica y, posiblemente, uso an\u00f3nimo en publicaciones.<br>&#8211; Puede revocar este consentimiento por escrito en cualquier momento (no retroactivo).<br>&#8211; El consultorio puede condicionar el tratamiento a la firma de este consentimiento.<\/p>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0, .wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0[data-kb-block=\"kb-adv-heading18305_f4f2b8-d0\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0[data-kb-block=\"kb-adv-heading18305_f4f2b8-d0\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_f4f2b8-d0[data-kb-block=\"kb-adv-heading18305_f4f2b8-d0\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_f4f2b8-d0 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_f4f2b8-d0\">Preferencias de comunicaci\u00f3n:<\/h3>\n\n\n<div class=\"kb-adv-form-field kb-field183054eb410-03 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb183054eb410-03\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Podemos llamarlo, enviarle un correo electr\u00f3nico o un mensaje de texto para confirmar Las citas?<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183054eb410-03_0\" name=\"field4eb410-03\"  value=\"Si\"><label for=\"field183054eb410-03_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183054eb410-03_1\" name=\"field4eb410-03\"  value=\"No\"><label for=\"field183054eb410-03_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1830589547d-2a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1830589547d-2a\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Podemos dejarle un mensaje en el buz\u00f3n de voz de su casa o celular?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830589547d-2a_0\" name=\"field89547d-2a\"  value=\"Si\"><label for=\"field1830589547d-2a_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830589547d-2a_1\" name=\"field89547d-2a\"  value=\"No\"><label for=\"field1830589547d-2a_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18305d095c2-8a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18305d095c2-8a\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Podemos discutir su condici\u00f3n m\u00e9dica con miembros de su familia?<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305d095c2-8a_0\" name=\"fieldd095c2-8a\"  value=\"Si\"><label for=\"field18305d095c2-8a_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305d095c2-8a_1\" name=\"fieldd095c2-8a\"  value=\"No\"><label for=\"field18305d095c2-8a_1\">No<\/label><\/div><\/fieldset><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col{display:flex;}.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col,.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_4a0be7-a5{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_4a0be7-a5 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_4a0be7-a5\"><div class=\"kt-inside-inner-col\"><style>.kadence-column18305_15ee09-80 > .kt-inside-inner-col{display:flex;}.kadence-column18305_15ee09-80 > .kt-inside-inner-col,.kadence-column18305_15ee09-80 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_15ee09-80 > .kt-inside-inner-col{row-gap:var(--global-kb-gap-sm, 1rem);column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_15ee09-80 > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_15ee09-80 > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_15ee09-80 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_15ee09-80{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_15ee09-80 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_15ee09-80 > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_15ee09-80\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-field1830518289_2d121e-05 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb1830518289_2d121e-05\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Asignaci\u00f3n de beneficios\/Divulgaci\u00f3n de informaci\u00f3n<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"field18289_2d121e-05\" id=\"field1830518289_2d121e-05_0\" data-label=\"Asignaci\u00f3n de beneficios\/Divulgaci\u00f3n de informaci\u00f3n\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field1830518289_2d121e-05_0\">I authorize my insurance provider (including Medicare and private insurers) to pay Sharma Rehabilitation Services PLLC<br>directly for medical services rendered. I also allow the release of necessary medical records to secure payment. A copy of<br>this agreement is as valid as the original<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18305c3088f-a6 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb18305c3088f-a6\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Autorizaci\u00f3n para la divulgaci\u00f3n de registros m\u00e9dicos<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"fieldc3088f-a6\" id=\"field18305c3088f-a6_0\" data-label=\"Autorizaci\u00f3n para la divulgaci\u00f3n de registros m\u00e9dicos\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field18305c3088f-a6_0\">Autorizo \u200b\u200ba Sharma Rehabilitation Services PLLC a solicitar y obtener todos los registros m\u00e9dicos m\u00edos y\/o de mi hijo de cualquier m\u00e9dico, hospital o proveedor de atenci\u00f3n m\u00e9dica.<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field18305635687-f8 wp-block-kadence-advanced-form-accept\"><fieldset class=\"kb-radio-check-item-wrap\" id=\"cb18305635687-f8\" data-type=\"accept\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Responsabilidad Financiera<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input name=\"field635687-f8\" id=\"field18305635687-f8_0\" data-label=\"Responsabilidad Financiera\" type=\"checkbox\" value=\"accept\" data-type=\"accept\" class=\"kb-field kb-accept-field kb-checkbox-field\" data-required=\"yes\" required aria-required=\"true\"\/><label for=\"field18305635687-f8_0\">Yo acepto pagar todos los copagos y cualquier saldo restante no cubierto por mi compa\u00f1\u00eda de seguros.<\/label><\/div><\/fieldset><\/div>\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e, .wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e[data-kb-block=\"kb-adv-heading18305_9da186-9e\"]{font-size:20px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e[data-kb-block=\"kb-adv-heading18305_9da186-9e\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18305_9da186-9e[data-kb-block=\"kb-adv-heading18305_9da186-9e\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h3 class=\"kt-adv-heading18305_9da186-9e wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18305_9da186-9e\"><strong>Consentimiento general para atenci\u00f3n y tratamiento<\/strong><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Al firmar a continuaci\u00f3n, usted autoriza a Bindu Sharma y al equipo cl\u00ednico a realizar los ex\u00e1menes m\u00e9dicos, pruebas y tratamientos necesarios para evaluar y controlar su condici\u00f3n.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Sus derechos y acuerdo:<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">&#8211; <strong>Elecci\u00f3n informada:<\/strong> Tiene derecho a hablar con su proveedor sobre su plan de tratamiento, incluyendo los prop\u00f3sitos, riesgos y beneficios de cualquier procedimiento recomendado.<br>&#8211; <strong>Alcance del consentimiento: <\/strong>Este consentimiento es permanente y se aplica a este centro y a cualquier oficina sat\u00e9lite de propiedad com\u00fan.<br>&#8211; <strong>Procedimientos adicionales: <\/strong>Si se requieren procedimientos invasivos o intervencionistas, se le proporcionar\u00e1 un formulario de consentimiento espec\u00edfico por separado.<br>&#8211; <strong>Revocaci\u00f3n: <\/strong>Puede suspender los servicios o revocar este consentimiento por escrito en cualquier momento.<br>&#8211; <strong>Reconocimiento: <\/strong>He le\u00eddo este formulario y solicito atenci\u00f3n voluntariamente. Entiendo que se me anima a hacer preguntas sobre cualquier prueba o tratamiento recomendado.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Al marcar las casillas a continuaci\u00f3n, reconozco que he le\u00eddo y acepto cada uno de los formularios de consentimiento y acuerdos enumerados anteriormente.<\/p>\n\n\n<div class=\"kb-adv-form-field kb-field18305f8cd55-32 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb18305f8cd55-32\" data-type=\"radio\" data-required=\"no\" ><legend class=\"kb-adv-form-label\">Aviso de HIPAA y consentimiento de privacidad<\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305f8cd55-32_0\" name=\"fieldf8cd55-32\"  value=\"Si\"><label for=\"field18305f8cd55-32_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field18305f8cd55-32_1\" name=\"fieldf8cd55-32\"  value=\"No\"><label for=\"field18305f8cd55-32_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field183055ba18c-2a wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb183055ba18c-2a\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Asignaci\u00f3n de beneficios\/Divulgaci\u00f3n de informaci\u00f3n<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183055ba18c-2a_0\" name=\"field5ba18c-2a\"  value=\"Si\"><label for=\"field183055ba18c-2a_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183055ba18c-2a_1\" name=\"field5ba18c-2a\"  value=\"No\"><label for=\"field183055ba18c-2a_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field183052afeb0-f0 wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb183052afeb0-f0\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Autorizaci\u00f3n para la divulgaci\u00f3n de registros m\u00e9dicos<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183052afeb0-f0_0\" name=\"field2afeb0-f0\"  value=\"Si\"><label for=\"field183052afeb0-f0_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field183052afeb0-f0_1\" name=\"field2afeb0-f0\"  value=\"No\"><label for=\"field183052afeb0-f0_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1830550a18e-bf wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1830550a18e-bf\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Responsabilidad financiera<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830550a18e-bf_0\" name=\"field50a18e-bf\"  value=\"SI\"><label for=\"field1830550a18e-bf_0\">SI<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830550a18e-bf_1\" name=\"field50a18e-bf\"  value=\"No\"><label for=\"field1830550a18e-bf_1\">No<\/label><\/div><\/fieldset><\/div>\n\n<div class=\"kb-adv-form-field kb-field1830574021a-6d wp-block-kadence-advanced-form-radio\"><fieldset class=\"kb-radio-check-item-wrap kb-radio-check-items-inline\" id=\"rb1830574021a-6d\" data-type=\"radio\" data-required=\"yes\" ><legend class=\"kb-adv-form-label\">Consentimiento general para atenci\u00f3n y tratamiento<span class=\"kb-adv-form-required\">*<\/span><\/legend><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830574021a-6d_0\" name=\"field74021a-6d\"  value=\"Si\"><label for=\"field1830574021a-6d_0\">Si<\/label><\/div><div class=\"kb-radio-check-item\"><input class=\"kb-radio-style\" type=\"radio\"  id=\"field1830574021a-6d_1\" name=\"field74021a-6d\"  value=\"No\"><label for=\"field1830574021a-6d_1\">No<\/label><\/div><\/fieldset><\/div>\n\n\n<p class=\"wp-block-paragraph\">Al firmar a continuaci\u00f3n, reconozco haber le\u00eddo y aceptado los t\u00e9rminos de cada formulario de autorizaci\u00f3n y consentimiento. Mi selecci\u00f3n constituye mi firma digital para los acuerdos espec\u00edficos mencionados anteriormente.<\/p>\n\n\n<style>.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:var(--global-kb-spacing-sm, 1.5rem);grid-template-columns:minmax(0, calc(35% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)))minmax(0, calc(40% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)))minmax(0, calc(25% - ((var(--global-kb-gap-md, 2rem) * 2 )\/3)));}.kb-row-layout-id18305_7b381b-d2 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}}@media all and (max-width: 1024px){.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap{grid-template-columns:repeat(3, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap > div:not(.added-for-specificity){grid-column:initial;}.kb-row-layout-id18305_7b381b-d2 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18305_7b381b-d2 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-3-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column18305_bcbf54-7d > .kt-inside-inner-col,.kadence-column18305_bcbf54-7d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_bcbf54-7d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_bcbf54-7d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_bcbf54-7d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_bcbf54-7d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_bcbf54-7d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_bcbf54-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_bcbf54-7d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_bcbf54-7d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305b594ce-f8 wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305b594ce-f8\">Este consentimiento fue firmado por:<\/label><input name=\"fieldb594ce-f8\" id=\"field18305b594ce-f8\" data-label=\"Este consentimiento fue firmado por:\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_c681d0-5d > .kt-inside-inner-col,.kadence-column18305_c681d0-5d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_c681d0-5d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_c681d0-5d > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_c681d0-5d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_c681d0-5d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_c681d0-5d{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_c681d0-5d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_c681d0-5d > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_c681d0-5d\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-text-type-input kb-adv-form-infield-type-input kb-field18305daa178-1a wp-block-kadence-advanced-form-text\"><label class=\"kb-adv-form-label\" for=\"field18305daa178-1a\">Firma del paciente\/padre\/tutor legal:<\/label><input name=\"fielddaa178-1a\" id=\"field18305daa178-1a\" data-label=\"Firma del paciente\/padre\/tutor legal:\" type=\"text\" placeholder=\"\" value=\"\" data-type=\"text\" class=\"kb-field kb-text-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n\n<style>.kadence-column18305_8fa64b-6a > .kt-inside-inner-col,.kadence-column18305_8fa64b-6a > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18305_8fa64b-6a > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18305_8fa64b-6a > .kt-inside-inner-col{flex-direction:column;}.kadence-column18305_8fa64b-6a > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18305_8fa64b-6a > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18305_8fa64b-6a{position:relative;}@media all and (max-width: 1024px){.kadence-column18305_8fa64b-6a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18305_8fa64b-6a > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18305_8fa64b-6a\"><div class=\"kt-inside-inner-col\"><div class=\"kb-adv-form-field kb-adv-form-infield-type-input kb-field183050968d5-18 wp-block-kadence-advanced-form-date\"><label class=\"kb-adv-form-label\" for=\"field183050968d5-18\">Fecha<\/label><input name=\"field0968d5-18\" id=\"field183050968d5-18\" data-label=\"Fecha\" type=\"date\" value=\"\" data-type=\"date\" class=\"kb-field kb-date-field\" data-required=\"no\" \/><\/div><\/div><\/div>\n\n<\/div><\/div><\/div><\/div>\n<\/div><\/div>\n\n\n<style>ul.menu .kb-submit-field .kb-btn1_default.kb-button{width:initial;}.kb-submit-field .kb-btn1_default.kb-button{text-transform:uppercase;}.kb-submit-field.kb-field1_default{justify-content:flex-start;}<\/style><div class=\"kb-adv-form-field kb-submit-field kb-field1_default wp-block-kadence-advanced-form-submit\"><button class=\"kb-button kt-button button kb-adv-form-submit-button kb-btn1_default kt-btn-size-small kt-btn-width-type-auto kb-btn-global-inherit kt-btn-has-text-true kt-btn-has-svg-false wp-block-button__link\" type=\"submit\"><span class=\"kt-btn-inner-text\">Submit Intake Form<\/span><\/button><\/div>\n<input type=\"hidden\" name=\"_kb_adv_form_post_id\" value=\"18305\"><input type=\"hidden\" name=\"action\" value=\"kb_process_advanced_form_submit\"><input type=\"hidden\" name=\"_kb_adv_form_id\" value=\"18305-cpt-id\"><\/form><\/div><\/div><\/div>\n<\/div><\/div>\n<\/div><\/div><\/div>\n<\/div><\/div>\n<\/div><\/div>\n\n<\/div><\/div>\n\n<style>.kb-row-layout-id18289_553713-b4 > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id18289_553713-b4 > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id18289_553713-b4 > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:var( --global-content-width, 1290px );padding-left:var(--global-content-edge-padding);padding-right:var(--global-content-edge-padding);padding-top:var(--global-kb-spacing-lg, 3rem);padding-bottom:var(--global-kb-spacing-3xl, 6.5rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id18289_553713-b4 > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id18289_553713-b4 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id18289_553713-b4 > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id18289_553713-b4 alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top kb-theme-content-width\">\n<style>.kadence-column18289_997567-fa > .kt-inside-inner-col,.kadence-column18289_997567-fa > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column18289_997567-fa > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column18289_997567-fa > .kt-inside-inner-col{flex-direction:column;}.kadence-column18289_997567-fa > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column18289_997567-fa > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column18289_997567-fa{position:relative;}@media all and (max-width: 1024px){.kadence-column18289_997567-fa > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}@media all and (max-width: 767px){.kadence-column18289_997567-fa > .kt-inside-inner-col{flex-direction:column;justify-content:center;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column18289_997567-fa\"><div class=\"kt-inside-inner-col\"><style>.kt-sc18289_4a3940-8f .kt-sc-imgcol, .kt-sc18289_4a3940-8f .kt-sc-textcol{min-height:450px;}.kt-sc18289_4a3940-8f .kt-sc-imgcol{background-size:cover;background-image:url(https:\/\/sharmarehab.com\/wp-content\/uploads\/2026\/04\/Book-Appointment.jpg);}.kt-sc18289_4a3940-8f .kt-sc-textcol{padding-top:var(--global-kb-spacing-3xl, 6.5rem);padding-right:var(--global-kb-spacing-3xl, 6.5rem);padding-bottom:var(--global-kb-spacing-3xl, 6.5rem);padding-left:var(--global-kb-spacing-xl, 4rem);margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;}@media all and (max-width: 1024px){.kt-sc18289_4a3940-8f .kt-sc-textcol{padding-top:var(--global-kb-spacing-xl, 4rem);padding-right:var(--global-kb-spacing-xxl, 5rem);padding-bottom:var(--global-kb-spacing-xl, 4rem);padding-left:var(--global-kb-spacing-lg, 3rem);}}@media all and (max-width: 767px){.kt-sc18289_4a3940-8f .kt-sc-imgcol, .kt-sc18289_4a3940-8f .kt-sc-textcol{min-height:250px;}.kt-sc18289_4a3940-8f .kt-sc-textcol{padding-top:var(--global-kb-spacing-lg, 3rem);padding-right:var(--global-kb-spacing-md, 2rem);padding-bottom:var(--global-kb-spacing-xl, 4rem);padding-left:var(--global-kb-spacing-md, 2rem);}}<\/style>\n<div class=\"aligncenter kt-sc18289_4a3940-8f wp-block-kadence-splitcontent\"><div class=\"kt-split-content-wrap kt-sc-media-side-left\" style=\"grid-template-columns:50% auto\"><div class=\"kt-sc-imgcol kt-sc-imgcol-bg-cover kt-sc-img-side-left\"><\/div><div class=\"kt-sc-textcol kt-sc-text-valign-center kt-sc-text-halign-left\" style=\"background-color:var(--global-palette7)\"><div class=\"kt-sc-innter-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52, .wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52[data-kb-block=\"kb-adv-heading18289_2077a6-52\"]{padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52[data-kb-block=\"kb-adv-heading18289_2077a6-52\"] mark.kt-highlight{font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}.wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52 img.kb-inline-image, .wp-block-kadence-advancedheading.kt-adv-heading18289_2077a6-52[data-kb-block=\"kb-adv-heading18289_2077a6-52\"] img.kb-inline-image{width:150px;vertical-align:baseline;}<\/style>\n<h2 class=\"kt-adv-heading18289_2077a6-52 wp-block-kadence-advancedheading\" data-kb-block=\"kb-adv-heading18289_2077a6-52\">Contact us<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Feel free to send in all your queries concerning our services, specialists, treatments, operations or appointment books. We have staff available to attend to you promptly.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Email:&nbsp;<\/strong><a href=\"mailto:info@sharmarehab.com\">info@sharmarehab.com<\/a><br><strong>Phone:&nbsp;<\/strong><a href=\"tel:1-718-878-0008\">718-878-0008<\/a>&nbsp;\/&nbsp;<a href=\"tel:1-718-928-3290\">718-928-3290<\/a><\/p>\n<\/div><\/div><\/div><\/div>\n<\/div><\/div>\n\n<\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Patient Intake Select Intake form language<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_kad_blocks_custom_css":"","_kad_blocks_head_custom_js":"","_kad_blocks_body_custom_js":"","_kad_blocks_footer_custom_js":"","_kad_post_transparent":"","_kad_post_title":"hide","_kad_post_layout":"","_kad_post_sidebar_id":"","_kad_post_content_style":"","_kad_post_vertical_padding":"","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","footnotes":""},"class_list":["post-18289","page","type-page","status-publish","hentry"],"taxonomy_info":[],"featured_image_src_large":false,"author_info":{"display_name":"Sharma Rehab","author_link":"https:\/\/sharmarehab.com\/es\/author\/gyamfi-bediako\/"},"comment_info":0,"_links":{"self":[{"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/pages\/18289","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/comments?post=18289"}],"version-history":[{"count":0,"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/pages\/18289\/revisions"}],"wp:attachment":[{"href":"https:\/\/sharmarehab.com\/es\/wp-json\/wp\/v2\/media?parent=18289"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}