{"id":4336,"date":"2026-04-05T12:54:43","date_gmt":"2026-04-05T12:54:43","guid":{"rendered":"https:\/\/myvidamed.org\/form\/"},"modified":"2026-04-19T14:56:22","modified_gmt":"2026-04-19T14:56:22","slug":"intake-form","status":"publish","type":"page","link":"https:\/\/myvidamed.com\/es\/intake-form\/","title":{"rendered":"Intake Form"},"content":{"rendered":"<div id=\"glp-form\">\n<form id=\"glp-multistep\" class=\"glp-multistep\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\n<input type=\"hidden\" name=\"action\" value=\"save_glp_form\" \/> \n<input type=\"hidden\" name=\"stripe-email-field\" class=\"stripe-email-field input\" \/>\n\n<!-- STEP 1 \u2014 Contact Information -->\n<div class=\"glp-step active\" data-step=\"1\">\n  <h2 class=\"mb-8\">Informaci\u00f3n del contacto<\/h2>\n<div class=\"sub-heading\">\n\tEste formulario toma aproximadamente de 2 a 3 minutos en completarse.<\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Nombre*<\/label>\n    <input name=\"name\" required autocomplete=\"name\">\n  <\/div>\n   <div class=\"col-6 mb-3 relative\">\n    <label>Apellido*<\/label>\n    <input type=\"text\" name=\"last_name\" required autocomplete=\"off\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Telefono *<\/label>\n    <input name=\"phone\" required autocomplete=\"off\" class=\"us-phone\"\n       value=\"+1 (___) ___ - ____\" mask=\"+1 (___) ___ - ____\" placeholder=\"+1 (___) ___ - ____\" >\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>Correo Electr\u00f3nico*<\/label>\n    <input type=\"email\" name=\"email\" required autocomplete=\"email\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <label>C\u00f3digo postal*<\/label>\n    <input name=\"zip\" required autocomplete=\"postal-code\">\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative recaptcha\">\n    <div class=\"g-recaptcha\" data-sitekey=\"6LeiRP0sAAAAAPPlFhM0ftyElJfgfJhmLqnocr76\"><\/div>\n  <\/div>\n\n  <div class=\"col-6 mb-3 relative\">\n    <button type=\"button\" class=\"save_first_setup_data next\">CONTINUAR<\/button>\n  <\/div>\n<\/div>\n\n\n<!-- STEPS 2\u20133 \u2014 Dynamic questions 5 & 6 -->\n<div class=\"glp-step\" data-step=\"2\">\n\n    \n    <div class=\"glp-question-block  wrap_question_5\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfCu\u00e1les son tus metas de p\u00e9rdida de peso?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Perder 1\u201320 libras de forma permanente\"\n                required            >\n                                    Perder 1-20 libras y sentirme como yo misma otra vez        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Perder 21\u201350 libras de forma permanente\"\n                            >\n                                    Perder 21-50 libras y recuperar mi energia        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Perder m\u00e1s de 50 libras de forma permanente\"\n                            >\n                                    Perder mas de 50 libras y transformar mi salud        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Mantener mi peso saludable\"\n                            >\n                                    Mantener mi peso y sentirme fuerte y saludable        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Ninguna de las anteriores\"\n                            >\n                                    Ninguna de las anteriores        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_5\"\n                value=\"Otra\"\n                            >\n                                    Otra        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"3\">\n\n    \n    <div class=\"glp-question-block  wrap_question_6\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfQu\u00e9 m\u00e9todos para bajar de peso has intentado en el pasado? Selecciona todas las que apliquen            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Ejercicio y dieta\"\n                            required                        >\n                        Ejercicio y dieta                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Suplementos para la p\u00e9rdida de peso\"\n                            required                        >\n                        Suplementos para la p\u00e9rdida de peso                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Ayuno intermitente\"\n                            required                        >\n                        Ayuno intermitente                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_6[]\"\n                            value=\"Ninguna de las anteriores\"\n                            required                        >\n                        Ninguna de las anteriores                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n\n\n<!-- STEP 4 \u2014 Treatment Options -->\n<div class=\"glp-step\" data-step=\"4\">\n\n  <h2>Opciones de tratamiento<\/h2>\n\n  \n    <div class=\"glp-question-block  wrap_question_7\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfCu\u00e1l opci\u00f3n de tratamiento te interesa m\u00e1s?             <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Select Box -->\n                    <div class=\"glp-field\">\n                        <select \n                            id =\"question_7\"\n                            name=\"question_7\" \n                            class=\"glp-select\"\n                            required                        >\n\n                            <option value=\"\"> Seleccione un medicamento<\/option>\n\n                                                        <option value=\"Semaglutida \u2014 INYECCI\u00d3N semanal \u2014 1 mes: $297\/mes\">\n                                Semaglutida \u2014 INYECCI\u00d3N semanal \u2014 Plan Mensual: $297\/mes                                    \n                            <\/option>\n                                                        <option value=\"Semaglutida \u2014 INYECCI\u00d3N semanal \u2014 3 meses: $197\/mes ($591 total) \u2014 \u00a1Ahorra $300!\">\n                                Semaglutida \u2014 INYECCI\u00d3N semanal \u2014 3 meses: $197\/mes ($591 total) \u2014 \u00a1Ahorra $300!                                    \n                            <\/option>\n                                                        <option value=\"Semaglutida \u2014 TABLETA diaria \u2014 1 mes: $297\/mes\">\n                                Semaglutida \u2014 TABLETA diaria \u2014 Plan Mensual: $297\/mes                                    \n                            <\/option>\n                                                        <option value=\"Semaglutida \u2014 TABLETA diaria \u2014 3 meses: $197\/mes ($591 total) \u2014 \u00a1Ahorra $300!\">\n                                Semaglutida \u2014 TABLETA diaria \u2014 3 meses: $197\/mes ($591 total) \u2014 \u00a1Ahorra $300!                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatida \u2014 INYECCI\u00d3N semanal \u2014 1 mes: $397\/mes\">\n                                Tirzepatida \u2014 INYECCI\u00d3N semanal \u2014 Plan Mensual: $397\/mes                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatida \u2014 INYECCI\u00d3N semanal \u2014 3 meses: $297\/mes ($891 total) \u2014 \u00a1Ahorra $300!\">\n                                Tirzepatida \u2014 INYECCI\u00d3N semanal \u2014 3 meses: $297\/mes ($891 total) \u2014 \u00a1Ahorra $300!                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatida \u2014 TABLETA diaria \u2014 1 mes: $397\/mes\">\n                                Tirzepatida \u2014 TABLETA diaria \u2014 Plan Mensual: $397\/mes                                    \n                            <\/option>\n                                                        <option value=\"Tirzepatida \u2014 TABLETA diaria \u2014 3 meses: $297\/mes ($891 total) \u2014 \u00a1Ahorra $300!\">\n                                Tirzepatida \u2014 TABLETA diaria \u2014 3 meses: $297\/mes ($891 total) \u2014 \u00a1Ahorra $300!                                    \n                            <\/option>\n                            \n                        <\/select>\n                    <\/div>\n\n                \n        \n    <\/div>\n\n    \n <p class=\"glp-note mb-5\">\n    Nota: Todas las opciones incluyen medicamento compuesto personalizado seg\u00fan lo recetado por tu doctor, todos los insumos necesarios, acompa\u00f1amiento m\u00e9dico continuo y env\u00edo gratuito a nivel nacional.  <\/p> \n\n  <input type=\"hidden\" name=\"product_id\" id=\"product_id\">\n\n  <div class=\"glp-info-box small-dot-list\">\n    <p>Toma en cuenta:<\/p>\n    <ul>\n      <li>Solo se realizar\u00e1 un cargo si el doctor aprueba el medicamento. Si no calificas, no se har\u00e1 ning\u00fan cobro.<\/li>\n      <li>Vidamed no realiza cargos autom\u00e1ticos. Tu tarjeta se guarda de forma segura en el portal para que no tengas que volver a ingresarla.<\/li>\n      <li>Para planes Mensuales: se cobra el precio del primer mes. Los meses siguientes se cobran al precio regular solo con tu aprobaci\u00f3n.<\/li>\n      <li>Para opciones de 3 meses: se realiza un \u00fanico pago por adelantado del monto total.<\/li>\n      <li>Siempre recibir\u00e1s recordatorios por mensaje de texto o correo electr\u00f3nico para aprobar futuros reabastecimientos.<\/li>\n    <\/ul>\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n    <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 5 \u2014 Physical Measurements -->\n<div class=\"glp-step\" data-step=\"5\">\n\n  <h2>Medidas f\u00edsicas<\/h2>\n\n  <div class=\"glp-question-block\">\n\n    <p class=\"glp-question mb-5\">\n      Por favor proporciona tus medidas f\u00edsicas e informaci\u00f3n demogr\u00e1fica:      <span class=\"required\">*<\/span>\n    <\/p>\n\n    <div class=\"glp-row\">\n\n      <!-- Height FT -->\n      <div class=\"glp-field\">\n        <label>Estatura (pies)<\/label>\n        <input type=\"number\" name=\"height_ft\" min=\"1\" max=\"8\" required>\n        <small class=\"glp-help-text\">Por favor ingresa un n\u00famero mayor o igual a 1<\/small>\n        <small class=\"glp-error-text\" data-error=\"height_ft\"><\/small>\n      <\/div>\n\n      <!-- Height IN -->\n      <div class=\"glp-field\">\n        <label>Estatura (pulgadas)<\/label>\n        <input type=\"number\" name=\"height_in\" min=\"0\" max=\"11\" required>\n        <small class=\"glp-help-text\">Por favor ingresa un n\u00famero del 0 al 11.<\/small>\n        <small class=\"glp-error-text\" data-error=\"height_in\"><\/small>\n      <\/div>\n\n    <\/div>\n\n    <!-- Weight -->\n    <div class=\"glp-field\">\n      <label>Peso (libras)<\/label>\n      <input type=\"number\" name=\"weight\" id=\"weight\" min=\"50\" max=\"700\" required>\n      <small class=\"glp-error-text\" data-error=\"weight\"><\/small>\n    <\/div>\n\n    <!-- BMI -->\n    <div class=\"glp-field\">\n      <label>IMC<\/label>\n      <input type=\"text\" name=\"bmi\" id=\"bmi\" readonly>\n    <\/div>\n\n    <!-- Gender -->\n    <div class=\"glp-field\" id=\"glp-field-gender\">\n      <label>G\u00e9nero<\/label>\n      <div class=\"glp-options\">\n        <label class=\"glp-option\">\n          <input type=\"radio\" name=\"gender\" value=\"male\" required>\n          Masculino         <\/label>\n        <label class=\"glp-option\">\n          <input type=\"radio\" name=\"gender\" value=\"female\">\n          Femenino        <\/label>\n      <\/div>\n      <small class=\"glp-error-text\" data-error=\"gender\"><\/small>\n    <\/div>\n\n    <!-- DOB -->\n    <div class=\"glp-field\">\n      <label>Fecha de nacimiento<\/label>\n      <input type=\"text\" name=\"dob\" id=\"dob\" required>\n      <small class=\"glp-error-text\" data-error=\"dob\"><\/small>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n    <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEPS 6\u201314 \u2014 Dynamic questions 11\u201319 -->\n<div class=\"glp-step\" data-step=\"6\">\n\n    \n    <div class=\"glp-question-block  wrap_question_11\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfEst\u00e1s tomando actualmente alg\u00fan medicamento GLP-1? (Requerido)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_11\"\n                value=\"S\u00ed\"\n                required            >\n                                    S\u00ed        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_11\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"7\">\n\n    \n    <div class=\"glp-question-block  wrap_question_12\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfEst\u00e1s embarazada, amamantando o planeas quedar embarazada en los pr\u00f3ximos 2 meses?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_12\"\n                value=\"S\u00ed\"\n                required            >\n                                    S\u00ed        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_12\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"8\">\n\n    \n    <div class=\"glp-question-block  wrap_question_13\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfTienes actualmente alguna de las siguientes condiciones m\u00e9dicas?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Gastroparesia\"\n                            required                        >\n                        Gastroparesia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"C\u00e1ncer de p\u00e1ncreas\"\n                            required                        >\n                        C\u00e1ncer de p\u00e1ncreas                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Pancreatitis\"\n                            required                        >\n                        Pancreatitis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Diabetes tipo 1 o diabetes que requiere insulina\"\n                            required                        >\n                        Diabetes tipo 1 o diabetes que requiere insulina                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Hipoglucemia\"\n                            required                        >\n                        Hipoglucemia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"C\u00e1ncer medular de tiroides (CMT) o antecedentes familiares de CMT\"\n                            required                        >\n                        C\u00e1ncer medular de tiroides (CMT) o antecedentes familiares de CMT                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Trastorno bipolar\"\n                            required                        >\n                        Trastorno bipolar                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Esquizofrenia\"\n                            required                        >\n                        Esquizofrenia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"S\u00edndrome de neoplasia endocrina m\u00faltiple tipo 2 (MEN-2) o antecedentes familiares de MEN-2\"\n                            required                        >\n                        S\u00edndrome de neoplasia endocrina m\u00faltiple tipo 2 (MEN-2) o antecedentes familiares de MEN-2                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Anorexia o bulimia\"\n                            required                        >\n                        Anorexia o bulimia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"C\u00e1lculos biliares sintom\u00e1ticos activos o enfermedad activa de la ves\u00edcula biliar\"\n                            required                        >\n                        C\u00e1lculos biliares sintom\u00e1ticos activos o enfermedad activa de la ves\u00edcula biliar                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Trastorno activo por uso de sustancias\"\n                            required                        >\n                        Trastorno activo por uso de sustancias                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_13[]\"\n                            value=\"Ninguna de las anteriores\"\n                            required                        >\n                        Ninguna de las anteriores                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"9\">\n\n    \n    <div class=\"glp-question-block  wrap_question_14\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Por favor marca todas las condiciones m\u00e9dicas actuales o pasadas. Selecciona todas las que apliquen            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Hipertensi\u00f3n (presi\u00f3n arterial alta)\"\n                            required                        >\n                        Hipertensi\u00f3n (presi\u00f3n arterial alta)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Colesterol alto\"\n                            required                        >\n                        Colesterol alto                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Diabetes tipo 2\"\n                            required                        >\n                        Diabetes tipo 2                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Apnea obstructiva del sue\u00f1o\"\n                            required                        >\n                        Apnea obstructiva del sue\u00f1o                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Gota\"\n                            required                        >\n                        Gota                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"S\u00edndrome metab\u00f3lico\"\n                            required                        >\n                        S\u00edndrome metab\u00f3lico                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Enfermedad card\u00edaca, accidente cerebrovascular o enfermedad vascular perif\u00e9rica\"\n                            required                        >\n                        Enfermedad card\u00edaca, accidente cerebrovascular o enfermedad vascular perif\u00e9rica                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Insuficiencia card\u00edaca\"\n                            required                        >\n                        Insuficiencia card\u00edaca                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Fibrilaci\u00f3n o aleteo auricular\"\n                            required                        >\n                        Fibrilaci\u00f3n o aleteo auricular                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Taquicardia o frecuencia card\u00edaca elevada\"\n                            required                        >\n                        Taquicardia o frecuencia card\u00edaca elevada                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Cualquier anomal\u00eda en el ECG o del ritmo card\u00edaco\"\n                            required                        >\n                        Cualquier anomal\u00eda en el ECG o del ritmo card\u00edaco                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Ves\u00edcula biliar extirpada\"\n                            required                        >\n                        Ves\u00edcula biliar extirpada                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"H\u00edgado graso (MASLD o MASH)\"\n                            required                        >\n                        H\u00edgado graso (MASLD o MASH)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Cirrosis o enfermedad hep\u00e1tica en etapa terminal\"\n                            required                        >\n                        Cirrosis o enfermedad hep\u00e1tica en etapa terminal                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Enfermedad renal cr\u00f3nica estadio 3 o mayor\"\n                            required                        >\n                        Enfermedad renal cr\u00f3nica estadio 3 o mayor                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Hipotiroidismo, hipertiroidismo o problemas de tiroides\"\n                            required                        >\n                        Hipotiroidismo, hipertiroidismo o problemas de tiroides                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_14[]\"\n                            value=\"Ninguna de las anteriores\"\n                            required                        >\n                        Ninguna de las anteriores                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"10\">\n\n    \n    <div class=\"glp-question-block  wrap_question_15\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfEst\u00e1s tomando actualmente alg\u00fan medicamento? Incluyendo medicamentos con receta, de venta libre y suplementos            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_15\"\n                    type=\"text\"\n                    name=\"question_15\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"11\">\n\n    \n    <div class=\"glp-question-block  wrap_question_16\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfTiene alguna alergia? (Si no tiene ninguna, escriba simplemente \u201cN\/A\u201d).            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_16\"\n                    type=\"text\"\n                    name=\"question_16\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"12\">\n\n    \n    <div class=\"glp-question-block  wrap_question_17\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Listar cualquier cirug\u00eda que hayas tenido en el pasado: Si no has tenido cirug\u00edas, escribe N\/A            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_17\"\n                    type=\"text\"\n                    name=\"question_17\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"13\">\n\n    \n    <div class=\"glp-question-block  wrap_question_18\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Por favor, suba una identificaci\u00f3n oficial con fotograf\u00eda (Requerido)            <span class=\"required\">*<\/span>        <\/p>\n\n                    <div class=\"glp-text sub-heading\">\n                La usamos \u00fanicamente para verificar su identidad y proteger su informaci\u00f3n. Aceptamos identificaciones oficiales extranjeras, como una identificaci\u00f3n mexicana. <\/div>\n            <div class=\"glp-field care-glp-upload-box\">\n\n    <label class=\"glp-upload-box\">\n\n        <input \n            type=\"file\"\n            name=\"question_18\"\n            accept=\"image\/*,.pdf\"\n            class=\"glp-input user_id_file\"\n            hidden\n            required        >\n\n        <div class=\"glp-upload-content\">\n            <p>Drag & drop your file here or click to upload<\/p>\n            <small>Accepted: JPG, PNG, PDF (Max 5MB)<\/small>\n        <\/div>\n\n    <\/label>\n\n    <div class=\"glp-file-preview\"><\/div>\n\n    <small class=\"glp-error-text\"><\/small>\n\n<\/div>\n\n\n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n<div class=\"glp-step\" data-step=\"14\">\n\n    \n    <div class=\"glp-question-block  wrap_question_19\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        \u00bfQu\u00e9 tipo de consulta prefieres?            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Correo electr\u00f3nico y mensaje de texto (Opci\u00f3n m\u00e1s r\u00e1pida)\"\n                required            >\n                                    Correo electr\u00f3nico y mensaje de texto (Opci\u00f3n m\u00e1s r\u00e1pida)        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Videollamada\"\n                            >\n                                    Videollamada        <\/label>\n    \n        <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_19\"\n                value=\"Llamada telef\u00f3nica\"\n                            >\n                                    Llamada telef\u00f3nica        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n        <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n    <\/div>\n\n<\/div>\n\n\n<!-- STEP 15 \u2014 Consent & Attestation -->\n<div class=\"glp-step\" data-step=\"15\">\n\n  <h2>Consentimiento y declaraci\u00f3n<\/h2>\n\n  <div class=\"glp-question-block consent-hide-q custom-input\">\n\n    <p class=\"glp-question mb-5\">\n      Por favor revise y confirme lo siguiente antes de continuar.      <br>\n      <strong>Consentimiento:<\/strong>\n      Confirmo que soy el\/la paciente que est\u00e1 completando este formulario de admisi\u00f3n y que he revisado cuidadosamente todas las preguntas. Declaro que mis respuestas son verdaderas, precisas y completas seg\u00fan mi leal saber y entender. Entiendo la importancia de proporcionar a mi m\u00e9dico informaci\u00f3n de salud completa y precisa para mi atenci\u00f3n.      <span class=\"required\">*<\/span>\n    <\/p>\n\n    \n    <div class=\"glp-question-block  wrap_question_20\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Porfavor confirma lo siguiente, atestando que toda la informaci\u00f3n que nos has proporcionado es verdadera y completa. Si no est\u00e1s de acuerdo, no podr\u00e1s enviar este formulario. Consentimiento: Confirmo que soy el paciente completando este formulario de admisi\u00f3n y he revisado todas las preguntas detenidamente. Declaro que mis respuestas son verdaderas, precisas y completas seg\u00fan mi mejor conocimiento. Entiendo la importancia de proporcionar a mi doctor informaci\u00f3n de salud completa y precisa para mi atenci\u00f3n.            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n    \n        <label class=\"glp-option single-option\">\n            <input \n                type=\"checkbox\"\n                name=\"question_20[]\"\n                value=\"Acepto y doy mi consentimiento.\"\n                required            >\n                                    Acepto y doy mi consentimiento.        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \n    <small class=\"glp-error-text\" data-error=\"consent\"><\/small>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n    <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 16 \u2014 Billing Information -->\n<div class=\"glp-step\" data-step=\"16\">\n\n  <h2 class=\"mb-5\">INFORMACI\u00d3N DE PAGO\n<\/h2>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>Direcci\u00f3n  <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"street\" id=\"street\"\n        placeholder=\"N\u00famero de casa, edificio\" required>\n      <small class=\"glp-error-text\" data-error=\"street\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Direcci\u00f3n postal<\/label>\n      <input type=\"text\" name=\"street2\" id=\"street2\"\n        placeholder=\"Nombre de la calle\">\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>Ciudad <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"city\" id=\"city\" required>\n      <small class=\"glp-error-text\" data-error=\"city\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label for=\"state\">Estado\/Provincia <span class=\"required\">*<\/span><\/label>\n      <select name=\"state\" id=\"state\" required>\n        <option value=\"\">Seleccione un estado<\/option>\n        <option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option>\n        <option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option>\n        <option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option>\n        <option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option>\n        <option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option>\n        <option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option>\n        <option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option>\n        <option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option>\n        <option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option>\n        <option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option>\n        <option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option>\n        <option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option>\n        <option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option>\n        <option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option>\n        <option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option>\n        <option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option>\n        <option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option>\n        <option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option>\n        <option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option>\n        <option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option>\n        <option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option>\n        <option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option>\n        <option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option>\n        <option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option>\n        <option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option>\n      <\/select>\n      <small class=\"glp-error-text\" data-error=\"state\"><\/small>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-row\">\n\n    <div class=\"glp-field mb-3\">\n      <label>C\u00f3digo postal <span class=\"required\">*<\/span><\/label>\n      <input type=\"text\" name=\"zip\" id=\"zip\" required>\n      <small class=\"glp-error-text\" data-error=\"zip\"><\/small>\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Pa\u00eds<\/label>\n      <select name=\"country\" id=\"country\">\n        <option value=\"US\">Estados Unidos<\/option>\n      <\/select>\n    <\/div>\n\n  <\/div>\n\n  <div class=\"glp-navigation\">\n    <button type=\"button\" class=\"prev\">Atr\u00e1s<\/button>\n    <button type=\"button\" class=\"next\">CONTINUAR<\/button>\n  <\/div>\n\n<\/div>\n\n\n<!-- STEP 17 \u2014 Payment (Stripe) -->\n<div class=\"glp-step stripe-page step-end\" data-step=\"17\">\n\n  <div class=\"glp-question-block\">\n\n    <div class=\"glp-field mb-3\">\n      <label for=\"promo_code\">C\u00f3digo promocional<\/label>\n      <input type=\"text\" name=\"promo_code\" id=\"promo_code\"\n        placeholder=\"Introduce el c\u00f3digo promocional\">\n    <\/div>\n\n    <div class=\"glp-field mb-3\">\n      <label>Pago <span class=\"required\">*<\/span><\/label>\n      <div id=\"card-element\" class=\"glp-stripe-card\"><\/div>\n      <div id=\"card-errors\" class=\"glp-error-text\"><\/div>\n      <div 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