{"id":461,"date":"2022-11-22T21:02:14","date_gmt":"2022-11-22T21:02:14","guid":{"rendered":"https:\/\/www.freshstart.org\/espanol\/?page_id=461"},"modified":"2025-05-17T00:03:12","modified_gmt":"2025-05-17T00:03:12","slug":"apply-for-help","status":"publish","type":"page","link":"https:\/\/www.freshstart.org\/espanol\/about-us\/apply-for-help\/","title":{"rendered":"Solicitar Ayuda"},"content":{"rendered":"<p>[vc_row el_class=&#8221;pgp-row-pad&#8221; css=&#8221;.vc_custom_1670143530291{padding-bottom: 100px !important;}&#8221;][vc_column][vc_custom_heading text=&#8221;Aplica Para Convertirte en Paciente de Fresh Start&#8221; font_container=&#8221;tag:h2|text_align:center&#8221; use_theme_fonts=&#8221;yes&#8221;][vc_column_text]Todos los d\u00edas, nuestra misi\u00f3n se hace realidad y cambiamos la vida de beb\u00e9s, ni\u00f1os y adolescentes desfavorecidos con deformidades f\u00edsicas y cosm\u00e9ticas causadas por defectos de nacimiento, accidentes, enfermedades o abuso, a trav\u00e9s del don de la cirug\u00eda pl\u00e1stica y reconstructiva. Ya sea un labio hendido o una cicatriz creada por abuso o quemaduras, podemos ayudar a realizar estas cirug\u00edas y muchas m\u00e1s. Todos los ni\u00f1os reciben atenci\u00f3n m\u00e9dica de la m\u00e1s alta calidad, independientemente de la capacidad de pago de las familias. Aceptamos solicitudes de todo <span class=\"pgp-nowrap\">Estados Unidos,<\/span> las familias nunca reciben una factura por <span class=\"pgp-nowrap\">el tratamiento.<\/span>[\/vc_column_text][vc_column_text]<\/p>\n<h3 class=\"fc-read-more\"><a href=\"https:\/\/apply.freshstart.org\/#\/\" target=\"_blank\" rel=\"noopener\">Empezar Solicitud<\/a><\/h3>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row disable_element=&#8221;yes&#8221; el_id=&#8221;patient-application&#8221;][vc_column]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f875-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"875\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/espanol\/wp-json\/wp\/v2\/pages\/461#wpcf7-f875-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=\"875\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f875-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"patient-application-form cw_cf7\">\n  <div id=\"cw_form\">\n      <ul class=\"cw_steps-nav\">\n          <li class=\"cw_form-step\">Paso 1<\/li>\n          <li class=\"cw_form-step\">Paso 2<\/li>\n          <li class=\"cw_form-step\">Paso 3<\/li>\n          <li class=\"cw_form-step\">Paso 4<\/li>\n          <li class=\"cw_form-step\">Paso 5<\/li>\n          <li class=\"cw_form-step\">Paso 6<\/li>\n      <\/ul>\n      <hr>\n  <\/div>\n\n  <div class=\"cw_steps cw_step1\">\n      <h2>Informaci\u00f3n de Paciente Solicitando Ayuda<\/h2>\n      <hr>\n      <h4>Gracias por su inter\u00e9s y entregar su solicitud a Fresh Start. Por favor indique si usted fue referido por:<\/h4>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"referred-by\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Rady Children&#039;s Hospital\" \/><span class=\"wpcf7-list-item-label\">Rady Children&#039;s Hospital<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Comer Children&#039;s Hospital\" \/><span class=\"wpcf7-list-item-label\">Comer Children&#039;s Hospital<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Hospital Infantil De Las Californias\" \/><span class=\"wpcf7-list-item-label\">Hospital Infantil De Las Californias<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Sanford Health\" \/><span class=\"wpcf7-list-item-label\">Sanford Health<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"University Health in San Antonio\" \/><span class=\"wpcf7-list-item-label\">University Health in San Antonio<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"OPSAM Health\" \/><span class=\"wpcf7-list-item-label\">OPSAM Health<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"True Care\" \/><span class=\"wpcf7-list-item-label\">True Care<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Google Search\" \/><span class=\"wpcf7-list-item-label\">Google Search<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Social Media\" \/><span class=\"wpcf7-list-item-label\">Social Media<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"News Program\" \/><span class=\"wpcf7-list-item-label\">News Program<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"referred-by[]\" value=\"Otro\" \/><span class=\"wpcf7-list-item-label\">Otro<\/span><\/label><\/span><\/span><\/span>\n      \n      <h4>Nombre<span class=\"cw_asterisk\"> *<\/span><\/h4>\n      <div class=\"cw_form-row\">\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-first-name\" \/><\/span>\n              Primer Nombre del Paciente:\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-middle-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-middle-name\" \/><\/span>\n              Medio Nombre:\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-last-name\" \/><\/span>\n              Apellido Nombre:\n          <\/label>\n      <\/div>\n      <h4>Direcci\u00f3n del Solicitante<span class=\"cw_asterisk\"> *<\/span><\/h4>\n      <div class=\"cw_form-row\">\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-street-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-street-address\" \/><\/span>\n              Direci\u00f3n de hogar:\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-city\" \/><\/span>\n              Cuidad:\n          <\/label>\n      <\/div>\n      <div class=\"cw_form-row\">\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-state\" \/><\/span>\n              Estado\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-zip\" \/><\/span>\n              Codigo Postal\n          <\/label>\n      <\/div>\n      <label>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-country\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-country\"><option value=\"Mexico\">Mexico<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Aland Islands\">Aland Islands<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Aguilla\">Aguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Austrailia\">Austrailia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"Brunei Darrussalam\">Brunei Darrussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Islands\">Christmas Islands<\/option><option value=\"Cocos Islands\">Cocos Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\">Congo, Republic of the<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\">Cote d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Curacao\">Curacao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Eswatini (Swaziland)\">Eswatini (Swaziland)<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard and McDonald Islands\">Heard and McDonald Islands<\/option><option value=\"Holy See\">Holy See<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Irag\">Irag<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macau\">Macau<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malwai\">Malwai<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Korea\">North Korea<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barthelemy\">Saint Barthelemy<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principle\">Sao Tome and Principle<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Sint Maarten\">Sint Maarten<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia\">South Georgia<\/option><option value=\"South Korea\">South Korea<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbar and Jan Mayen Islands\">Svalbar and Jan Mayen Islands<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States\">United States<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"US Minor Outlying Islands\">US Minor Outlying Islands<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuata\">Vanuata<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span>\n          Pa\u00eds\n      <\/label>\n      <label>Condado de Residencia<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-county-of-residence\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-county-of-residence\" \/><\/span>\n      <\/label>\n      <label>Pa\u00eds de Residencia<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-country-of-residence\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-country-of-residence\"><option value=\"Mexico\">Mexico<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Aland Islands\">Aland Islands<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Aguilla\">Aguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Austrailia\">Austrailia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"Brunei Darrussalam\">Brunei Darrussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Islands\">Christmas Islands<\/option><option value=\"Cocos Islands\">Cocos Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\">Congo, Republic of the<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\">Cote d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Curacao\">Curacao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Eswatini (Swaziland)\">Eswatini (Swaziland)<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard and McDonald Islands\">Heard and McDonald Islands<\/option><option value=\"Holy See\">Holy See<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Irag\">Irag<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macau\">Macau<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malwai\">Malwai<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Korea\">North Korea<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barthelemy\">Saint Barthelemy<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principle\">Sao Tome and Principle<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Sint Maarten\">Sint Maarten<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia\">South Georgia<\/option><option value=\"South Korea\">South Korea<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbar and Jan Mayen Islands\">Svalbar and Jan Mayen Islands<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States\">United States<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"US Minor Outlying Islands\">US Minor Outlying Islands<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuata\">Vanuata<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span>\n      <\/label>\n      <h4>Si no est\u00e1 en los EE.UU., \u00bfel paciente y el padre tienen pasaporte?<\/h4>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-passport\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"app-passport[]\" value=\"Si\" \/><span class=\"wpcf7-list-item-label\">Si<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"app-passport[]\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n      \n      <label>El paciente y Padre de familia tiene visa?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-visas\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"app-visas\"><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/span>\n      <\/label>\n      <label>Necesitaran transporte?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-transportation\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"app-transportation\"><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/span>\n      <\/label>\n      <label>Numero de Telefono<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-phone\"><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\" value=\"\" type=\"tel\" name=\"app-phone\" \/><\/span>\n      <\/label>\n      <label>Correo Electronico<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-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\" value=\"\" type=\"email\" name=\"app-email\" \/><\/span>\n      <\/label>\n      <label>del Solicitante Fecha de Nacimiento<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-DOB\"><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=\"app-DOB\" \/><\/span>\n      <\/label>\n      <br>\n      <label>G\u00e9nero<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-sex\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-sex\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Masculino\">Masculino<\/option><option value=\"Femenino\">Femenino<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <label>Pa\u00eds de Ciudadan\u00eda del Solicitante\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-citizenship\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"app-citizenship\"><option value=\"Mexico\">Mexico<\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Aland Islands\">Aland Islands<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"American Samoa\">American Samoa<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Aguilla\">Aguilla<\/option><option value=\"Antarctica\">Antarctica<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Aruba\">Aruba<\/option><option value=\"Austrailia\">Austrailia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bermuda\">Bermuda<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bonaire, Sint Eustatius and Saba\">Bonaire, Sint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Bouvet Island\">Bouvet Island<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"British Indian Ocean Territory\">British Indian Ocean Territory<\/option><option value=\"Brunei Darrussalam\">Brunei Darrussalam<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Cayman Islands\">Cayman Islands<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Christmas Islands\">Christmas Islands<\/option><option value=\"Cocos Islands\">Cocos Islands<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo, Democratic Republic of the\">Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\">Congo, Republic of the<\/option><option value=\"Cook Islands\">Cook Islands<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d&#039;Ivoire\">Cote d&#039;Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Curacao\">Curacao<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Eswatini (Swaziland)\">Eswatini (Swaziland)<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Falkland Islands\">Falkland Islands<\/option><option value=\"Faroe Islands\">Faroe Islands<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"France\">France<\/option><option value=\"French Guiana\">French Guiana<\/option><option value=\"French Polynesia\">French Polynesia<\/option><option value=\"French Southern Territories\">French Southern Territories<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Gibraltar\">Gibraltar<\/option><option value=\"Greece\">Greece<\/option><option value=\"Guadeloupe\">Guadeloupe<\/option><option value=\"Guam\">Guam<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guernsey\">Guernsey<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Heard and McDonald Islands\">Heard and McDonald Islands<\/option><option value=\"Holy See\">Holy See<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hong Kong\">Hong Kong<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Irag\">Irag<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Isle of Man\">Isle of Man<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jersey\">Jersey<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\">Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macau\">Macau<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malwai\">Malwai<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Martinique\">Martinique<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mayotte\">Mayotte<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Montserrat\">Montserrat<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Caledonia\">New Caledonia<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Niue\">Niue<\/option><option value=\"Norfolk Island\">Norfolk Island<\/option><option value=\"North Korea\">North Korea<\/option><option value=\"Northern Mariana Islands\">Northern Mariana Islands<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palau\">Palau<\/option><option value=\"Palestine, State of\">Palestine, State of<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Pitcairn\">Pitcairn<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Puerto Rico\">Puerto Rico<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Reunion\">Reunion<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Barthelemy\">Saint Barthelemy<\/option><option value=\"Saint Helena\">Saint Helena<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Martin\">Saint Martin<\/option><option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principle\">Sao Tome and Principle<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Sint Maarten\">Sint Maarten<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"South Georgia\">South Georgia<\/option><option value=\"South Korea\">South Korea<\/option><option value=\"South Sudan\">South Sudan<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Svalbar and Jan Mayen Islands\">Svalbar and Jan Mayen Islands<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Timor-Leste\">Timor-Leste<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tokelau\">Tokelau<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States\">United States<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"US Minor Outlying Islands\">US Minor Outlying Islands<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuata\">Vanuata<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Virgin Islands, British\">Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\">Virgin Islands, U.S.<\/option><option value=\"Wallis and Futuna\">Wallis and Futuna<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><\/span>\n      <\/label>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"next()\">Siguiente<\/a>\n      <\/div>\n  <\/div>\n\n  <div class=\"cw_steps cw_step2\">\n      <h2>Informaci\u00f3n Sobre el Padre\/Guardian<\/h2>\n      <hr>\n      <h4>Nombre del Padre de Familia \/ Guardian<span class=\"cw_asterisk\"> *<\/span><\/h4>\n      <div class=\"cw_form-row\">\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-first-name\" \/><\/span>\n              Primer Nombre del Paciente:\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-last-name\" \/><\/span>\n              Apellido Nombre:\n          <\/label>\n      <\/div>\n      <label>Fecha de nacimiento del padre\/tutor<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-DOB\"><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=\"pg-DOB\" \/><\/span>\n      <\/label>\n      <br>\n      <label>\u00bfDirecci\u00f3n igual que el paciente?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-app-address\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pg-app-address\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><\/select><\/span>\n      <\/label>\n      <div id=\"pg-diff-address\">\n          <h4>Direcci\u00f3n<\/h4>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-address\" \/><\/span>\n              Direcci\u00f3n\n          <\/label>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-address2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-address2\" \/><\/span>\n              L\u00ednea de direcci\u00f3n 2\n          <\/label>\n          <div class=\"cw_form-row\">\n              <label>\n                  <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-city\" \/><\/span>\n                  Ciudad\n              <\/label>\n              <label>\n                  <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-state\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-state\" \/><\/span>\n                  Estado \/ Provincia \/ Regi\u00f3n\n              <\/label>\n          <\/div>\n          <div class=\"cw_form-row\">\n              <label>\n                  <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-zip\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-zip\" \/><\/span>\n                  C\u00f3digo postal\n              <\/label>\n              <label>\n                  [select pg-country default:\"Mexico\" \"Afghanistan\" \"Aland Islands\" \"Albania\" \"Algeria\" \"American Samoa\" \"Andorra\" \"Angola\" \"Aguilla\" \"Antarctica\" \"Antigua and Barbuda\" \"Argentina\" \"Armenia\" \"Aruba\" \"Austrailia\" \"Austria\" \"Azerbaijan\" \"Bahamas\" \"Bahrain\" \"Bangladesh\" \"Barbados\" \"Belarus\" \"Belgium\" \"Belize\" \"Benin\" \"Bermuda\" \"Bhutan\" \"Bolivia\" \"Bonaire, Sint Eustatius and Saba\" \"Bosnia and Herzegovina\" \"Botswana\" \"Bouvet Island\" \"Brazil\" \"British Indian Ocean Territory\" \"Brunei Darrussalam\" \"Bulgaria\" \"Burkina Faso\" \"Burundi\" \"Cambodia\" \"Cameroon\" \"Canada\" \"Cape Verde\" \"Cayman Islands\" \"Central African Republic\" \"Chad\" \"Chile\" \"China\" \"Christmas Islands\" \"Cocos Islands\" \"Colombia\" \"Comoros\" \"Congo, Democratic Republic of the\" \"Congo, Republic of the\" \"Cook Islands\" \"Costa Rica\" \"Cote d'Ivoire\" \"Croatia\" \"Cuba \"Curacao\" \"Cyprus\" \"Czech Republic\" \"Denmark\" \"Djibouti\" \"Dominica\" \"Dominican Republic\" \"Ecuador\" \"Egypt\" \"El Salvador\" \"Equatorial Guinea\" \"Eritrea\" \"Estonia\" \"Eswatini (Swaziland)\" \"Ethiopia\" \"Falkland Islands\" \"Faroe Islands\" \"Fiji\" \"France\" \"French Guiana\" \"French Polynesia\" \"French Southern Territories\" \"Gabon\" \"Georgia\" \"Germany\" \"Ghana\" \"Gibraltar\" \"Greece\" \"Guadeloupe\" \"Guam\" \"Guatemala\" \"Guernsey\" \"Guinea\" \"Guinea-Bissau\" \"Guyana\" \"Haiti\" \"Heard and McDonald Islands\" \"Holy See\" \"Honduras\" \"Hong Kong\" \"Hungary\" \"Iceland\" \"India\" \"Indonesia\" \"Iran\" \"Irag\" \"Ireland\" \"Isle of Man\" \"Israel\" \"Italy\" \"Jamaica\" \"Japan\" \"Jersey\" \"Jordan\" \"Kazakhstan\" \"Kenya\" \"Kiribati\" \"Kuwait\" \"Kyrgyzstan\" \"Lao People's Democratic Republic\" \"Latvia\" \"Lebanon\" \"Lesotho\" \"Liberia\" \"Libya\" \"Liechtenstein\" \"Lithuania\" \"Luxembourg\" \"Macau\" \"Macedonia\" \"Madagascar\" \"Malwai\" \"Malaysia\" \"Maldives\" \"Mali\" \"Malta\" \"Marshall Islands\" \"Martinique\" \"Mauritania\" \"Mauritius\" \"Mayotte\" \"Mexico\" \"Micronesia\" \"Moldova\" \"Monaco\" \"Mongolia\" \"Montenegro\" \"Montserrat\" \"Morocco\" \"Mozambique\" \"Myanmar\" \"Namibia\" \"Nauru\" \"Nepal\" \"Netherlands\" \"New Caledonia\" \"New Zealand\" \"Nicaragua\" \"Niger\" \"Nigeria\" \"Niue\" \"Norfolk Island\" \"North Korea\" \"Northern Mariana Islands\" \"Norway\" \"Oman\" \"Pakistan\" \"Palau\" \"Palestine, State of\" \"Panama\" \"Papua New Guinea\" \"Paraguay\" \"Peru\" \"Philippines\" \"Pitcairn\" \"Poland\" \"Portugal\" \"Puerto Rico\" \"Qatar\" \"Reunion\" \"Romania\" \"Russia\" \"Rwanda\" \"Saint Barthelemy\" \"Saint Helena\" \"Saint Kitts and Nevis\" \"Saint Lucia\" \"Saint Martin\" \"Saint Pierre and Miquelon\" \"Saint Vincent and the Grenadines\" \"Samoa\" \"San Marino\" \"Sao Tome and Principle\" \"Saudi Arabia\" \"Senegal\" \"Serbia\" \"Seychelles\" \"Sierra Leone\" \"Singapore\" \"Sint Maarten\" \"Slovakia\" \"Slovenia\" \"Solomon Islands\" \"Somalia\" \"South Africa\" \"South Georgia\" \"South Korea\" \"South Sudan\" \"Spain\" \"Sri Lanka\" \"Sudan\" \"Suriname\" \"Svalbar and Jan Mayen Islands\" \"Sweden\" \"Switzerland\" \"Syria\" \"Taiwan\" \"Tajikistan\" \"Tanzania\" \"Thailand\" \"Timor-Leste\" \"Togo\" \"Tokelau\" \"Tonga\" \"Trinidad and Tobago\" \"Tunisia\" \"Turkey\" \"Turkmenistan\" \"Turks and Caicos Islands\" \"Tuvalu\" \"Uganda\" \"Ukraine\" \"United Arab Emirates\" \"United Kingdom\" \"United States\" \"Uruguay\" \"US Minor Outlying Islands\" \"Uzbekistan\" \"Vanuata\" \"Venezuela\" \"Vietnam\" \"Virgin Islands, British\" \"Virgin Islands, U.S.\" \"Wallis and Futuna\" \"Western Sahara\" \"Yemen\" \"Zambia\" \"Zimbabwe\"]\n                  Pa\u00eds\n              <\/label>\n          <\/div>\n          <label>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-county-of-residence\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pg-county-of-residence\" \/><\/span>\n              Pa\u00eds de residencia\n          <\/label>\n      <\/div>\n      <div class=\"cw_form-row\">\n          <label>Tel\u00e9fono\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"pg-phone\" \/><\/span>\n          <\/label>\n          <label>Correo electr\u00f3nico\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"pg-email\" \/><\/span>\n          <\/label>\n      <\/div>\n      <label>G\u00e9nero del Padre\/Tutor\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"pg-sex\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"pg-sex\"><option value=\"Masculino\">Masculino<\/option><option value=\"Femenino\">Femenino<\/option><\/select><\/span>\n      <\/label>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"nextStep(-1)\">Previo<\/a>\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"next()\">Siguiente<\/a>\n      <\/div>\n  <\/div>\n\n  <div class=\"cw_steps cw_step3\">\n      <h2>Descripci\u00f3n de Condici\u00f3n<\/h2>\n      <p>La siguiente es una lista de procedimientos quir\u00farqicos que se llevan a cabo en Fresh Start. Seleccione el tipo de cirug\u00eda o el tratamiento que necesita:<\/p>\n      <hr>\n      <label>Seleccione el Tipo de Cirug\u00eda o el Tratamiento Que Necesita<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-condition\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-condition\"><option value=\"Microtia\">Microtia<\/option><option value=\"Scar Revisions\">Scar Revisions<\/option><option value=\"Otoplasty\">Otoplasty<\/option><option value=\"Cleft Lip &amp; Palate Repair\">Cleft Lip &amp; Palate Repair<\/option><option value=\"Septo-Rhinoplasty\">Septo-Rhinoplasty<\/option><option value=\"Lefort I, II, III\">Lefort I, II, III<\/option><option value=\"Mandibular &amp; Maxillary Osteotomies\">Mandibular &amp; Maxillary Osteotomies<\/option><option value=\"Excisions of lesions with\/out tissue expanders\">Excisions of lesions with\/out tissue expanders<\/option><option value=\"Burn contracture procedure\">Burn contracture procedure<\/option><option value=\"Polydactyly hands &amp; feet\">Polydactyly hands &amp; feet<\/option><option value=\"Tongue Reduction\">Tongue Reduction<\/option><option value=\"Gynecomastia\">Gynecomastia<\/option><option value=\"Poland Syndrome Reconstruction\">Poland Syndrome Reconstruction<\/option><option value=\"Strabismus &amp; other eye procedures\">Strabismus &amp; other eye procedures<\/option><option value=\"Treacher-Collins Syndrome Procedures\">Treacher-Collins Syndrome Procedures<\/option><option value=\"Laser Procedures for Vascular Lesions\">Laser Procedures for Vascular Lesions<\/option><option value=\"Facial Hypoplasia Procedures\">Facial Hypoplasia Procedures<\/option><option value=\"Other\">Other<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <label>Si respondi\u00f3 \"Otro\", \u00bfcu\u00e1l es la condici\u00f3n?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-other-condition\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"app-other-condition\" \/><\/span>\n      <\/label>\n      <br>\n      <label>La Condici\u00f3n es Relacionada a un<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-reason-for-condition\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-reason-for-condition\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Defecto de nacimiento cong\u00e9nito\">Defecto de nacimiento cong\u00e9nito<\/option><option value=\"Accidente o Trauma\">Accidente o Trauma<\/option><option value=\"acto violento\">acto violento<\/option><option value=\"No aplica\">No aplica<\/option><option value=\"Otro\">Otro<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <label>Condiciones relacionadas\/Otros problemas de salud:<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-other-problems\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-other-problems\"><\/textarea><\/span>\n      <\/label>\n      <br>\n      <label>Alergias\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-allergies\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-allergies\"><\/textarea><\/span>\n      <\/label>\n      <br>\n      <label>Medicamentos que usa:\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-medications\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-medications\"><\/textarea><\/span>\n      <\/label>\n      <hr>\n      <div class=\"cw_form-row\">\n          <div>\n              <h4>Nombre del m\u00e9dico<\/h4>\n              <div class=\"cw_form-row\">\n                  <label>\n                      <span class=\"wpcf7-form-control-wrap\" data-name=\"physician-first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physician-first-name\" \/><\/span>\n                      Primer Nombre\n                  <\/label>\n                  <label>\n                      <span class=\"wpcf7-form-control-wrap\" data-name=\"physician-last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"physician-last-name\" \/><\/span>\n                      Apellido\n                  <\/label>\n              <\/div>\n          <\/div>\n          <div>\n              <h4>N\u00famero del m\u00e9dico<\/h4>\n              <label>\n                  <span class=\"wpcf7-form-control-wrap\" data-name=\"physician-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"physician-phone\" \/><\/span>\n                  Tel\u00e9fono\n              <\/label>\n          <\/div>\n      <\/div>\n      <hr>\n      <label>\u00bfHa recibido el paciente tratamiento para la condici\u00f3n?<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-received-treatment\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-received-treatment\"><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><\/select><\/span>\n      <\/label>\n      <div id=\"app-no-treatment\">\n          <label>Si contesto \u201cS\u00ed\u201d describa los tratamientos\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-previous-treatments\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-previous-treatments\"><\/textarea><\/span>\n          <\/label>\n          <label>Describa brevemente el tipo de cirug\u00eda o tratamiento necesario y por qu\u00e9.\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-describe-why-treatment\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-describe-why-treatment\"><\/textarea><\/span>\n          <\/label>\n      <\/div>\n      <div class=\"cw_form-row\">\n          <label>\u00bfTiene seguro medico el paciente perspectivo?<span class=\"cw_asterisk\"> *<\/span>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"app-medical-insurance\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-medical-insurance\"><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><\/select><\/span>\n          <\/label>\n          <div id=\"app-no-insurance\">\n              <label>Si contesto \u201cS\u00ed\u201d, cual es el seguro medico\n                  <span class=\"wpcf7-form-control-wrap\" data-name=\"app-insurance-type\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-insurance-type\"><\/textarea><\/span>\n              <\/label>\n          <\/div>\n      <\/div>\n      <label>\u00bfHa sido rechazado coberutra para su condicion?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-denied-insurance\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"app-denied-insurance\"><option value=\"Si\">Si<\/option><option value=\"No\">No<\/option><\/select><\/span>\n      <\/label>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"nextStep(-1)\">Previo<\/a>\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"next()\">Siguiente<\/a>\n      <\/div>\n  <\/div>\n\n  <div class=\"cw_steps cw_step4\">\n      <h2>Informaci\u00f3n de Hogar<\/h2>\n      <p>Haga una lista de nombre del solicitante y miembros de su familia. Incluya fuente de ingresos\/ tipo de empleo, edad, parentezco con el paciente, ingreso anual, y si la persona esta bajo el cargo de un adulto. Incluya SSI, SSD, SS, IHSS, pension elimenticia, manutencion para menores, pension y cualquier otro tipo de asistencia monetaria recibida regularmente:<\/p>\n      <hr>\n      <label>Total del Ingreso Anual de la Familia<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-family-members\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"app-family-members\"><\/textarea><\/span>\n      <\/label>\n      <div class=\"cw_form-row\">\n          <label>Ingreso anual bruto total del hogar:<span class=\"cw_asterisk\"> *<\/span>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"household-income\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"household-income\" \/><\/span>\n          <\/label>\n          <label>Cantidad de gastos mensuales:<span class=\"cw_asterisk\"> *<\/span>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"monthly-expenses\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"monthly-expenses\" \/><\/span>\n          <\/label>\n      <\/div>\n      <div class=\"cw_form-row\">\n          <label>Cantidad total de activos:<span class=\"cw_asterisk\"> *<\/span>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"total-assets\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"total-assets\" \/><\/span>\n          <\/label>\n          <label>Cantidad total de pasivos:<span class=\"cw_asterisk\"> *<\/span>\n              <span class=\"wpcf7-form-control-wrap\" data-name=\"total-liabilities\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"total-liabilities\" \/><\/span>\n          <\/label>\n      <\/div>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"nextStep(-1)\">Previo<\/a>\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"next()\">Siguiente<\/a>\n      <\/div>\n  <\/div>\n\n  <div class=\"cw_steps cw_step5\">\n      <h2>Encuesta de pacientes potenciales (17 a\u00f1os o m\u00e1s)<\/h2>\n      <hr>\n      <label>Por favor comparta ejemplos\/comentarios que expliquen por que solicita la ayuda de Fresh Start:\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"learn-fresh-start\"><textarea cols=\"40\" rows=\"5\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"learn-fresh-start\"><\/textarea><\/span>\n      <\/label>\n      <br>\n      <label>Por lo general mi salud es:\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-overall-health\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-overall-health\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Pobre\">Pobre<\/option><option value=\"Justo\">Justo<\/option><option value=\"Bueno\">Bueno<\/option><option value=\"Excelente\">Excelente<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <hr>\n      <label>\u00bfCuanto dolor corporal ha tenido?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-bodily-pain\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-bodily-pain\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Ninguna\">Ninguna<\/option><option value=\"Templado\">Templado<\/option><option value=\"Moderato\">Moderato<\/option><option value=\"Grave\">Grave<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <hr>\n      <label>Mi condici\u00f3n ha afctado mis actividades sociales\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-social-activities\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-social-activities\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"De ning\u00fan modo\">De ning\u00fan modo<\/option><option value=\"Ligeramente\">Ligeramente<\/option><option value=\"Moderato\">Moderato<\/option><option value=\"A menudo\">A menudo<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <hr>\n      <label>\u00bfPor lo general se siente contento \u00f3 fel\u00edz?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-happiness\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"app-happiness\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Nunca\">Nunca<\/option><option value=\"A veces\">A veces<\/option><option value=\"A menudo\">A menudo<\/option><option value=\"Siempre\">Siempre<\/option><\/select><\/span>\n      <\/label>\n      <br>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"nextStep(-1)\">Previo<\/a>\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"next()\">Siguiente<\/a>\n      <\/div>\n  <\/div>\n\n  <div class=\"cw_steps cw_step6\">\n      <h2>Documentos necesarios para a\u00f1adir a la solicitud antes de enviar<\/h2>\n      <p>Adjunte: registros m\u00e9dicos, fotograf\u00edas, informaci\u00f3n del seguro\/carta de denegaci\u00f3n. Las solicitudes sin fotograf\u00edas no pueden ser procesadas. Llame al (760) 448-2023 para obtener m\u00e1s informaci\u00f3n. Evite las im\u00e1genes borrosas y aseg\u00farese de que estas im\u00e1genes sean legibles.<\/p>\n      <hr>\n      <label>Si respondi\u00f3 \"s\u00ed\" a la denegaci\u00f3n de cobertura de seguro, cargue una copia de la carta de denegaci\u00f3n.\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"denial-letter\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"denial-letter\" \/><\/span>\n      <\/label>\n      <br>\n      <label>Adjunte fotograf\u00edas actuales de vista frontal y lateral del \u00e1rea problem\u00e1tica\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"photo-problem\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"photo-problem\" \/><\/span>\n      <\/label>\n      <br>\n      <label>Adjunte copias de todos los registros m\u00e9dicos relacionados con los tratamientos que ha recibido para su problema.\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-medical-records\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"treatment-medical-records\" \/><\/span>\n      <\/label>\n      <br>\n      <label>Adjunte una copia del certificado de nacimiento del paciente\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"app-birth-certificate\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"app-birth-certificate\" \/><\/span>\n      <\/label>\n      <br>\n      <label>\u00bfSi es ciudadano de EE.UU., por favor adjunte una copia de la mas reciente declaracion de impuestos (IRS)?\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"tax-return\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"tax-return\" \/><\/span>\n      <\/label>\n      <h2>Firma y fecha<\/h2>\n      <p>Declaro bajo pena de perjurio que lo anterior es una declaraci\u00f3n verdadera y precisa en cuanto a la disponibilidad de cualquier seguro o reembolso financiado por el estado para la cirug\u00eda solicitada de Fresh Start Surgical Gift, Inc.<\/p>\n      <hr>\n      <label>Firma<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"signature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"signature\" \/><\/span>\n      <\/label>\n      <label>Fecha<span class=\"cw_asterisk\"> *<\/span>\n          <span class=\"wpcf7-form-control-wrap\" data-name=\"signed-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"signed-date\" \/><\/span>\n      <\/label>\n      <hr>\n      <p class=\"cw_missing-required\">Faltan campos obligatorios<\/p>\n      <div class=\"cw_form-buttons\">\n          <a href=\"#cw_form\" class=\"cw_form-btn\" onclick=\"nextStep(-1)\">Previo<\/a>\n          <input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Enviar\" \/>\n      <\/div>\n  <\/div>\n<\/div><div class=\"wpcf7-response-output\" 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