{"id":9117,"date":"2022-10-07T15:12:49","date_gmt":"2022-10-07T22:12:49","guid":{"rendered":"https:\/\/plasticatijuana.com\/solicitud-para-cirugia-plastica-2\/"},"modified":"2025-02-18T09:46:19","modified_gmt":"2025-02-18T17:46:19","slug":"solicitud-para-cirugia-plastica-2","status":"publish","type":"page","link":"https:\/\/plasticatijuana.com\/es\/solicitud-para-cirugia-plastica-2\/","title":{"rendered":"Solicitud para cirug\u00eda pl\u00e1stica"},"content":{"rendered":"<style>.elementor-9117 .elementor-element.elementor-element-7de79e39{--display:flex;--flex-direction:row;--container-widget-width:initial;--container-widget-height:100%;--container-widget-flex-grow:1;--container-widget-align-self:stretch;--flex-wrap-mobile:wrap;--padding-top:100px;--padding-bottom:100px;--padding-left:100px;--padding-right:100px;}.elementor-9117 .elementor-element.elementor-element-7de79e39:not(.elementor-motion-effects-element-type-background), .elementor-9117 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.elementor-motion-effects-layer{background-attachment:fixed;}}<\/style>\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9117\" class=\"elementor elementor-9117 elementor-1702\" data-elementor-settings=\"{&quot;element_pack_global_tooltip_width&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true}}\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7de79e39 e-flex e-con-boxed e-con e-parent\" data-id=\"7de79e39\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;shape_divider_bottom&quot;:&quot;triangle&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-shape elementor-shape-bottom\" aria-hidden=\"true\" data-negative=\"false\">\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 1000 100\" preserveAspectRatio=\"none\">\n\t<path class=\"elementor-shape-fill\" d=\"M500,98.9L0,6.1V0h1000v6.1L500,98.9z\"\/>\n<\/svg>\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-216da2b2 e-con-full e-flex e-con e-child\" data-id=\"216da2b2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-47f45421 elementor-widget elementor-widget-text-editor\" data-id=\"47f45421\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>SOLICITUD DE <span style=\"color: #e3b17b;\"><strong>CIRUG\u00cdA PL\u00c1STICA<\/strong><\/span><\/p>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-54f43902 e-flex e-con-boxed e-con e-child\" data-id=\"54f43902\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-01bcb17 e-flex e-con-boxed e-con e-parent\" data-id=\"01bcb17\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7106742 elementor-widget elementor-widget-jkit_contact_form_7\" data-id=\"7106742\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"jkit_contact_form_7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div  class=\"jeg-elementor-kit jkit-contact-form-7 jeg_module___69d4526b6bc42\" >\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f3333-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"3333\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/9117#wpcf7-f3333-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"3333\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f3333-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"col-md-6\" style=\"letter-spacing: 0;\">\n\t<p>Have you received any treatment with us before?* <span class=\"wpcf7-form-control-wrap\" data-name=\"have-you\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"have-you\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"have-you\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name*\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name*\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"bio-sex\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Biological Sex*\" value=\"\" type=\"text\" name=\"bio-sex\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" title=\"Birth Date*\" style=\"letter-spacing: 0;\">\n\t<div style=\"border-bottom: solid 1px #535353!important; padding: 0 0 0 15px;\">\n\t\t<p style=\"float: left;\" class=\"tam-date-surgery\">Birth Date*\n\t\t<\/p>\n\t\t<p style=\"margin-top: 0px!important;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"birth-date\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Age*\" value=\"\" type=\"text\" name=\"age\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-tel\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone*\" value=\"\" type=\"tel\" name=\"your-tel\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email*\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address*\" value=\"\" type=\"text\" name=\"your-address\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Zip code\" value=\"\" type=\"text\" name=\"zip-code\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"City*\" value=\"\" type=\"text\" name=\"your-city\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"State*\" value=\"\" type=\"text\" name=\"your-state\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-country\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Country*\" value=\"\" type=\"text\" name=\"your-country\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-services\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Services*\" value=\"\" type=\"text\" name=\"your-services\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\" title=\"Procedure of Interest*\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-procedure\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"your-procedure\"><option value=\"Procedure of Interest*\">Procedure of Interest*<\/option><option value=\"Liposculpture\">Liposculpture<\/option><option value=\"Tummy Tuck\">Tummy Tuck<\/option><option value=\"Face Lift\">Face Lift<\/option><option value=\"Breast Augmentation\">Breast Augmentation<\/option><option value=\"Brazilian Butt Lift\">Brazilian Butt Lift<\/option><option value=\"Mommy Makeover\">Mommy Makeover<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-conatct3\">\n\t<div class=\"col-md-12\" style=\"padding: 3px 15px; background-color: #000; color: white; letter-spacing: 0;\">\n\t\t<p>Do you take any medications\/drugs?* <span class=\"wpcf7-form-control-wrap\" data-name=\"medications-drugs\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"medications-drugs\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"medications-drugs\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-12\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"specify-medications\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Specify medications*\" value=\"\" type=\"text\" name=\"specify-medications\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-12\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"why-taking\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Why are you taking them?*\" value=\"\" type=\"text\" name=\"why-taking\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-12\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"how-long-taking\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"How long have you been taking them?*\" value=\"\" type=\"text\" name=\"how-long-taking\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-6 brd-1\" style=\"letter-spacing: 0;\">\n\t<p>Do you take, or have you take in the past Blood-thinners?* <span class=\"wpcf7-form-control-wrap\" data-name=\"blood-thinners\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"blood-thinners\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"blood-thinners\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-2\" style=\"letter-spacing: 0;\">\n\t<p>Penicillin* <span class=\"wpcf7-form-control-wrap\" data-name=\"penicillin\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"penicillin\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"penicillin\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-2\" style=\"letter-spacing: 0;\">\n\t<p>Sulfa Drugs* <span class=\"wpcf7-form-control-wrap\" data-name=\"sulfa-drugs\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sulfa-drugs\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sulfa-drugs\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Iodine* <span class=\"wpcf7-form-control-wrap\" data-name=\"iodine\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"iodine\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"iodine\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Tape* <span class=\"wpcf7-form-control-wrap\" data-name=\"tape\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"tape\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"tape\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Latex* <span class=\"wpcf7-form-control-wrap\" data-name=\"latex\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"latex\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"latex\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Aspirin* <span class=\"wpcf7-form-control-wrap\" data-name=\"aspirin\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"aspirin\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"aspirin\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>High lipid levels* <span class=\"wpcf7-form-control-wrap\" data-name=\"lipid-levels\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"lipid-levels\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"lipid-levels\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact2\" style=\"letter-spacing: 0;\">\n\t<p style=\"padding: 3px 15px; background-color: #000; color: white;\">Previous Bariatric Surgery*\n\t<\/p>\n\t<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"which-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Which one?*\" value=\"\" type=\"text\" name=\"which-one\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"what-age\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"What was your age?*\" value=\"\" type=\"text\" name=\"what-age\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"what-year\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"What year was it performed?*\" value=\"\" type=\"text\" name=\"what-year\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"complications\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Any complications?*\" value=\"\" type=\"text\" name=\"complications\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Date of surgery*\">\n\t\t<div style=\"border-bottom: solid 1px #535353!important; padding: 0 0 0 15px;\">\n\t\t\t<p style=\"float: left;\" class=\"tam-date-surgery\">Date of surgery*\n\t\t\t<\/p>\n\t\t\t<p style=\"margin-top: 0px!important;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"date-surgery\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date color\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-surgery\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-6 brd-1\" style=\"letter-spacing: 0;\">\n\t<p>Have you ever had a problem with an anesthetic?* <span class=\"wpcf7-form-control-wrap\" data-name=\"anesthetic\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"anesthetic\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"anesthetic\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-6 brd-2\" style=\"letter-spacing: 0;\">\n\t<p>Do you smoke cigarettes?* <span class=\"wpcf7-form-control-wrap\" data-name=\"smoke-cigarettes\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"smoke-cigarettes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"smoke-cigarettes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-4 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Do you drink alcohol?* <span class=\"wpcf7-form-control-wrap\" data-name=\"drink-alcohol\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"drink-alcohol\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"drink-alcohol\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-4 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Use recreational drugs?* <span class=\"wpcf7-form-control-wrap\" data-name=\"recreational-drugs\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"recreational-drugs\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"recreational-drugs\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-4 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Are you easy fatigued?* <span class=\"wpcf7-form-control-wrap\" data-name=\"easy-fatigued\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"easy-fatigued\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"easy-fatigued\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-6 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Do you have shortness of breath?* <span class=\"wpcf7-form-control-wrap\" data-name=\"breath\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"breath\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"breath\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-6 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Do you have asthma?* <span class=\"wpcf7-form-control-wrap\" data-name=\"asthma\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"asthma\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"asthma\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Stroke* <span class=\"wpcf7-form-control-wrap\" data-name=\"stroke\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"stroke\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"stroke\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Diabetes* <span class=\"wpcf7-form-control-wrap\" data-name=\"diabetes\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"diabetes\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"diabetes\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-6 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Coronary Artery Disease* <span class=\"wpcf7-form-control-wrap\" data-name=\"coronary\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"coronary\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"coronary\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Liver disease* <span class=\"wpcf7-form-control-wrap\" data-name=\"liver\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"liver\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"liver\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Lung disease* <span class=\"wpcf7-form-control-wrap\" data-name=\"lung\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"lung\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"lung\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Renal disease* <span class=\"wpcf7-form-control-wrap\" data-name=\"renal\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"renal\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"renal\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-3 brd-4\" style=\"letter-spacing: 0;\">\n\t<p>Thyroid disease* <span class=\"wpcf7-form-control-wrap\" data-name=\"thyroide\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"thyroide\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"thyroide\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-4 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Hypertension* <span class=\"wpcf7-form-control-wrap\" data-name=\"hypertension\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hypertension\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hypertension\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact\">\n\t<div class=\"col-md-12\" style=\"padding: 3px 15px; background-color: #000; color: white; letter-spacing: 0;\">\n\t\t<p>Any other illnesses* <span class=\"wpcf7-form-control-wrap\" data-name=\"illnesses\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"illnesses\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"illnesses\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-12\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"specify-conditions\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Specify conditions*\" value=\"\" type=\"text\" name=\"specify-conditions\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Date of last menstrual period*\">\n\t<div style=\"border-bottom: solid 1px #535353!important; padding: 0 0 0 15px;\">\n\t\t<p class=\"date-menstrual\">Date of last menstrual period*\n\t\t<\/p>\n\t\t<p id=\"date-last-menstrual-period\" style=\"margin-top: 0px!important;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"menstrual-period\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"menstrual-period\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-6\" style=\"letter-spacing: 0;\">\n\t<p>Do you use any type of birth control?* <span class=\"wpcf7-form-control-wrap\" data-name=\"type-birth-control\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"type-birth-control\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"type-birth-control\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact\">\n\t<p style=\"padding: 3px 15px; background-color: #000; color: white;\"> Birth Control*\n\t<\/p>\n\t<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"type\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Type*\" value=\"\" type=\"text\" name=\"type\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-8\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"birth-control\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required color\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"How long have you used this birth control?*\" value=\"\" type=\"text\" name=\"birth-control\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-12 brd-1\" style=\"letter-spacing: 0;\">\n\t<p>Are you presently, or have you ever taken hormones?* <span class=\"wpcf7-form-control-wrap\" data-name=\"hormones\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"hormones\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"hormones\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-7 brd-3\" style=\"letter-spacing: 0;\">\n\t<p>Are you presently, or is there a possibility of you being pregnant?* <span class=\"wpcf7-form-control-wrap\" data-name=\"pregnant\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"pregnant\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"pregnant\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-5 brd-4\">\n\t<p>Have you had any previous surgery?* <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"previous-surgery\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"previous-surgery\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact\">\n\t<p style=\"padding: 3px 15px; background-color: #000; color: white;\">Previous Surgery\n\t<\/p>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"what-surgery\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"What surgery?*\" value=\"\" type=\"text\" name=\"what-surgery\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"what-age2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"What was your age?*\" value=\"\" type=\"text\" name=\"what-age2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"what-year2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"What year was it performed?*\" value=\"\" type=\"text\" name=\"what-year2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"complications2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Any complications?*\" value=\"\" type=\"text\" name=\"complications2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-6 brd-1\" style=\"letter-spacing: 0;\">\n\t<p>Do you use or B-PAP while your sleep?* <span class=\"wpcf7-form-control-wrap\" data-name=\"sleep\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"sleep\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"sleep\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"col-md-6 brd-2\" style=\"letter-spacing: 0;\">\n\t<p>Do you exercise?* <span class=\"wpcf7-form-control-wrap\" data-name=\"exercise\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"exercise\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"exercise\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact\">\n\t<p style=\"padding: 3px 15px; background-color: #000; color: white;\">Exercise\n\t<\/p>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"type2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Type*\" value=\"\" type=\"text\" name=\"type2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"how-long\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"How long?*\" value=\"\" type=\"text\" name=\"how-long\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"how-frecuent\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"How frecuent?*\" value=\"\" type=\"text\" name=\"how-frecuent\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"hours-days\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text color\" aria-invalid=\"false\" placeholder=\"Hours per day?*\" value=\"\" type=\"text\" name=\"hours-days\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"religion\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Religion*\" value=\"\" type=\"text\" name=\"religion\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"preferred-language\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Preferred language*\" value=\"\" type=\"text\" name=\"preferred-language\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\" title=\"How did you know about us?*\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"know-aboutus\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"know-aboutus\"><option value=\"How did you know about us?*\">How did you know about us?*<\/option><option value=\"Facebook\">Facebook<\/option><option value=\"Instagram\">Instagram<\/option><option value=\"Google\">Google<\/option><option value=\"Referred\">Referred<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-3\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"which-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Which other?*\" value=\"\" type=\"text\" name=\"which-other\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-12\" style=\"letter-spacing: 0;\" title=\"When are you planning on having surgery?*\">\n\t<div style=\"border-bottom: solid 1px #535353!important; padding: 0 0 0 15px;\">\n\t\t<p style=\"float: left;\" class=\"tam-planning-surgery\">When are you planning on having surgery?*\n\t\t<\/p>\n\t\t<p id=\"planning-surgery\" style=\"margin-top: 0px!important;\"><span class=\"wpcf7-form-control-wrap\" data-name=\"date-planning-surgery\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date-planning-surgery\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"sty-part-contact4\">\n\t<div class=\"col-md-12\" style=\"margin-bottom: 5px; padding-top: 6px; padding-bottom: 6px; background-color: #000; color: white; letter-spacing: 0;\">\n\t\t<p><span style=\"letter-spacing: 1px; font-weight: 800\">Photographs:<\/span> Completely Naked so doctors can have a clear view of surgical areas for evaluation.\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Front*\">\n\t\t<p>Front*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-front\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".jpg,.png,.jpeg\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"your-front\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Back*\">\n\t\t<p>Back*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-back\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".jpg,.png,.jpeg\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"your-back\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"separador clear\">\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Left side*\">\n\t\t<p>Left side*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-left\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".jpg,.png,.jpeg\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"your-left\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n\t<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Right side*\">\n\t\t<p>Right side*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-right\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".jpg,.png,.jpeg\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"your-right\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"mobile separador\">\n\t<\/div>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-6\" style=\"letter-spacing: 0;\" title=\"Select your preferred measurement system\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"measurement-system\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"measurement-system\"><option value=\"Select your preferred measurement system\">Select your preferred measurement system<\/option><option value=\"Imperial (lb - in )\">Imperial (lb - in )<\/option><\/select><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-6\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"max-weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Max weight (lb)*\" value=\"\" type=\"text\" name=\"max-weight\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"current-weight\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Current weight (lb)*\" value=\"\" type=\"text\" name=\"current-weight\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"height\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Height (ft)*\" value=\"\" type=\"text\" name=\"height\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"mobile separador\">\n<\/div>\n<div class=\"col-md-4\" style=\"letter-spacing: 0;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"bmi\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"BMI*\" value=\"\" type=\"text\" name=\"bmi\" \/><\/span>\n\t<\/p>\n<\/div>\n<div class=\"separador-mini clear\">\n<\/div>\n<div class=\"col-md-12 style=\"letter-spacing: 0;\"\">\n\t<p>REFERENCES\n\t<\/p>\n\t<ul>\n\t\t<li>\n\t\t\t<p>For your evaluation this info must be submitted. The surgeons will evaluate your case based on a overall individualized cased. Surgical plan can be changed upon consult face to face evaluation.\n\t\t\t<\/p>\n\t\t<\/li>\n\t<\/ul>\n<\/div>\n<div class=\"separador clear\">\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner btn-application\" type=\"submit\" value=\"Send\" \/>\n<\/p>\n<div class=\"separador clear\">\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>SOLICITUD DE CIRUG\u00cdA PL\u00c1STICA Have you received any treatment with us before?* YesNo Birth Date* Procedure of Interest*LiposculptureTummy TuckFace LiftBreast AugmentationBrazilian Butt LiftMommy Makeover Do you take any medications\/drugs?* YesNo Do you take, or have you take in the past Blood-thinners?* YesNo Penicillin* YesNo Sulfa Drugs* YesNo Iodine* YesNo Tape* YesNo Latex* YesNo Aspirin* YesNo [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-9117","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - 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