{"id":435,"date":"2023-01-18T08:57:02","date_gmt":"2023-01-18T12:57:02","guid":{"rendered":"https:\/\/misimagenes.online\/web\/?page_id=435"},"modified":"2025-07-30T07:31:49","modified_gmt":"2025-07-30T11:31:49","slug":"solicitud-de-estudio-de-imagenes","status":"publish","type":"page","link":"https:\/\/misimagenes.online\/web\/solicitud-de-estudio-de-imagenes\/","title":{"rendered":"Solicitud de Estudios de Im\u00e1genes"},"content":{"rendered":"\n<div class=\"wp-block-group alignfull has-background-color has-text-color has-background has-link-color wp-elements-cbe5736373a35858ea99fb1b25c19091 is-layout-constrained wp-block-group-is-layout-constrained\" style=\"background-color:#292929;padding-top:6rem;padding-bottom:6rem\">\n<div class=\"wp-block-group alignwide is-layout-flow wp-block-group-is-layout-flow\"><div class='fluentform ff-default fluentform_wrapper_15  ff_guten_block ff_guten_block-15 ffs_default_wrap'><form data-form_id=\"15\" id=\"fluentform_15\" class=\"frm-fluent-form fluent_form_15 ff-el-form-top ff_form_instance_15_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_15_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Solicitud de Estudios &#8211; Tlf<\/legend>        <div\n                style=\"display: none!important; position: absolute!important; transform: translateX(1000%)!important;\"\n                class=\"ff-el-group ff-hpsf-container\"\n        >\n            <div class=\"ff-el-input--label asterisk-right\">\n                <label for=\"ff_15_item_sf\" aria-label=\"Subscribe\">\n                    Subscribe                <\/label>\n            <\/div>\n            <div class=\"ff-el-input--content\">\n                <input type=\"text\"\n                       name=\"item_15__fluent_sf\"\n                       class=\"ff-el-form-control\"\n                       id=\"ff_15_item_sf\"\n                \/>\n            <\/div>\n        <\/div>\n        <input type='hidden' name='__fluent_form_embded_post_id' value='435' \/><input type=\"hidden\" id=\"_fluentform_15_fluentformnonce\" name=\"_fluentform_15_fluentformnonce\" value=\"3af01d064f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/web\/wp-json\/wp\/v2\/pages\/435\" \/><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><input type=\"hidden\" name=\"hidden\" value=\"  - \" data-name=\"hidden\" ><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><input type=\"hidden\" name=\"hidden_1\" value=\"05\/06\/2026\" data-name=\"hidden_1\" ><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-15_1\" ><p>&nbsp;<\/p>\n<h3><strong>Datos del Paciente<\/strong><\/h3><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_4 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 25%;'><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_15_names_first_name_' id='label_ff_15_names_first_name_' >Primer Nombre<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_15_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Como aparece en la c\u00e9dula\" tabindex=\"1\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 25%;'><div data-type=\"name-element\" data-name=\"Apelllido\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_15_Apelllido_last_name_' id='label_ff_15_Apelllido_last_name_' >Primer Apellido<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Apelllido[last_name]\" id=\"ff_15_Apelllido_last_name_\" class=\"ff-el-form-control\" placeholder=\"Si es casada, coloque su apellido de Soltera\" tabindex=\"2\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_15_Edad' id='label_ff_15_Edad' aria-label=\"Edad\">Edad<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"Edad\" value=\"20\" class=\"ff-el-form-control\" placeholder=\"\u00bfCu\u00e1l es la edad del paciente?\" maxlength=\"2\" data-name=\"Edad\" tabindex=\"3\" id=\"ff_15_Edad\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-4' style='flex-basis: 25%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_15_CedulaID' id='label_ff_15_CedulaID' aria-label=\"C\u00e9dula\">C\u00e9dula<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"CedulaID\" class=\"ff-el-form-control\" placeholder=\"00000000\" maxlength=\"9\" data-name=\"CedulaID\" tabindex=\"4\" id=\"ff_15_CedulaID\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-15_2\" ><h4>\u00a0<\/h4>\n<p><strong>Podemos enviar un mensaje de texto al paciente para que programe la cita de su estudio<\/strong><\/p><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Enviar mensaje de texto\">Enviar mensaje de texto<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check- ff_item_selected'><label class='ff-el-form-check-label' for=input_radio_83d53ea520111cc2a2d038bfe0879783><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" checked=\"1\" tabindex=\"5\" value=\"S\u00ed\"  id='input_radio_83d53ea520111cc2a2d038bfe0879783' aria-label='S\u00ed' aria-invalid='false' aria-required=false> <span>S\u00ed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_ff7efa224916e999931f85e24653f008><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" tabindex=\"-1\" value=\"no\"  id='input_radio_ff7efa224916e999931f85e24653f008' aria-label='No' aria-invalid='false' aria-required=false> <span>No<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_15_dropdown' id='label_ff_15_dropdown' aria-label=\"C\u00f3digo del celular\">C\u00f3digo del celular<\/label><\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_15_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\" tabindex=\"6\"  aria-invalid=\"false\" aria-required=\"false\" aria-labelledby=\"label_ff_15_dropdown\"><option value=\"\">&#8211; Select &#8211;<\/option><option value=\"414\"  >414<\/option><option value=\"424\"  >424<\/option><option value=\"416\"  >416<\/option><option value=\"426\"  >426<\/option><option value=\"412\"  >412<\/option><option value=\"417\"  >417<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_15_input_mask' id='label_ff_15_input_mask' aria-label=\"N\u00famero de celular\">N\u00famero de celular<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_mask\" data-mask=\"###-####\" class=\"ff-el-form-control\" data-name=\"input_mask\" tabindex=\"7\" id=\"ff_15_input_mask\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-15_3\" ><p>&nbsp;<\/p>\n<h3><strong>Estudio(s) solicitado(s):<\/strong><\/h3><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_3 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"MAMOGRAF\u00cdA\">MAMOGRAF\u00cdA<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_bf251b1265b1204c8193f29362766950><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"8\" value=\"Mamograf\u00eda Digital\"  id='checkbox_16_bf251b1265b1204c8193f29362766950' aria-label='Mamograf\u00eda Digital' aria-invalid='false' aria-required=false> <span>Mamograf\u00eda Digital<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_e78f4b71633b0bfacc25f8a439a8b787><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mamograf\u00eda Unilateral Derecha\"  id='checkbox_16_e78f4b71633b0bfacc25f8a439a8b787' aria-label='Mamograf\u00eda Unilateral Derecha' aria-invalid='false' aria-required=false> <span>Mamograf\u00eda Unilateral Derecha<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_494e278d0564ba8a386f17eda9931164><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mamograf\u00eda Unilateral Izquierda\"  id='checkbox_16_494e278d0564ba8a386f17eda9931164' aria-label='Mamograf\u00eda Unilateral Izquierda' aria-invalid='false' aria-required=false> <span>Mamograf\u00eda Unilateral Izquierda<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16_9b976caa7fb31aa6678de700fc5f6798><input  type=\"checkbox\" name=\"checkbox_16[]\" data-name=\"checkbox_16\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Tomos\u00edntesis (Mamograf\u00eda 3D)\"  id='checkbox_16_9b976caa7fb31aa6678de700fc5f6798' aria-label='Tomos\u00edntesis (Mamograf\u00eda 3D)' aria-invalid='false' aria-required=false> <span>Tomos\u00edntesis (Mamograf\u00eda 3D)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Estudios Odontol\u00f3gicos - ATM\">Estudios Odontol\u00f3gicos &#8211; ATM<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_8a405522436cf25d5d8bee74bffcb9f0><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"9\" value=\"Panor\u00e1mica Dental\"  id='checkbox_2_8a405522436cf25d5d8bee74bffcb9f0' aria-label='Panor\u00e1mica Dental' aria-invalid='false' aria-required=false> <span>Panor\u00e1mica Dental<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_b7b7f8eb63eff0c339b6ae2adcb55e9c><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Cef\u00e1lica Lateral\"  id='checkbox_2_b7b7f8eb63eff0c339b6ae2adcb55e9c' aria-label='Cef\u00e1lica Lateral' aria-invalid='false' aria-required=false> <span>Cef\u00e1lica Lateral<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_ea14cf898baac1056af4017907187814><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Articulaci\u00f3n Temporomandibular\"  id='checkbox_2_ea14cf898baac1056af4017907187814' aria-label='Articulaci\u00f3n Temporomandibular' aria-invalid='false' aria-required=false> <span>Articulaci\u00f3n Temporomandibular<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Rx Digital\">Rx Digital<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7be1f41200a3abca3c98f39603ddc856><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"10\" value=\"Abdomen simple de pie\"  id='checkbox_7be1f41200a3abca3c98f39603ddc856' aria-label='Abdomen simple de pie' aria-invalid='false' aria-required=false> <span>Abdomen simple de pie<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_a2fcd90415bea61f6ad393e651f01da5><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Abdomen KUB\"  id='checkbox_a2fcd90415bea61f6ad393e651f01da5' aria-label='Abdomen KUB' aria-invalid='false' aria-required=false> <span>Abdomen KUB<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_5dfec2b8fb74a827cb9f16482697e260><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Cr\u00e1neo 2P\"  id='checkbox_5dfec2b8fb74a827cb9f16482697e260' aria-label='Cr\u00e1neo 2P' aria-invalid='false' aria-required=false> <span>Cr\u00e1neo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8f61c3f639bc82da0a51125942d0a7f6><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Cr\u00e1neo 3P\"  id='checkbox_8f61c3f639bc82da0a51125942d0a7f6' aria-label='Cr\u00e1neo 3P' aria-invalid='false' aria-required=false> <span>Cr\u00e1neo 3P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8bd829cedd84f00d7fbaa000000cc0a8><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Senos Paranasales\"  id='checkbox_8bd829cedd84f00d7fbaa000000cc0a8' aria-label='Senos Paranasales' aria-invalid='false' aria-required=false> <span>Senos Paranasales<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_868b884f3f1bcf9dd77a610a0ffd488b><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Rinofaringe BA - BC\"  id='checkbox_868b884f3f1bcf9dd77a610a0ffd488b' aria-label='Rinofaringe BA - BC' aria-invalid='false' aria-required=false> <span>Rinofaringe BA &#8211; BC<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_f237f8b735531c88ab6cd38dd28e3a69><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Huesos propios de la nariz\"  id='checkbox_f237f8b735531c88ab6cd38dd28e3a69' aria-label='Huesos propios de la nariz' aria-invalid='false' aria-required=false> <span>Huesos propios de la nariz<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_c3b59238a78878c62de6237425c531b7><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Edad \u00f3sea (Ambas Manos 1P)\"  id='checkbox_c3b59238a78878c62de6237425c531b7' aria-label='Edad \u00f3sea (Ambas Manos 1P)' aria-invalid='false' aria-required=false> <span>Edad \u00f3sea (Ambas Manos 1P)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_bcb331faa910c8bc8cc64d0d1f247208><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Medici\u00f3n de miembros inferiores\"  id='checkbox_bcb331faa910c8bc8cc64d0d1f247208' aria-label='Medici\u00f3n de miembros inferiores' aria-invalid='false' aria-required=false> <span>Medici\u00f3n de miembros inferiores<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-3' style='flex-basis: 33.33%;'><div class='ff-el-group'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_7bc8247919fa83ce123ba81f0d18be67><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"11\" value=\"Columna Cervical\"  id='checkbox_4_7bc8247919fa83ce123ba81f0d18be67' aria-label='Columna Cervical' aria-invalid='false' aria-required=false> <span>Columna Cervical<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_50402bf054f846840209116a8c1bf88f><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Columna Dorsolumbar\"  id='checkbox_4_50402bf054f846840209116a8c1bf88f' aria-label='Columna Dorsolumbar' aria-invalid='false' aria-required=false> <span>Columna Dorsolumbar<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_902ff205007c409cad75d8c6eea5bb5c><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Columna Lumbosacra\"  id='checkbox_4_902ff205007c409cad75d8c6eea5bb5c' aria-label='Columna Lumbosacra' aria-invalid='false' aria-required=false> <span>Columna Lumbosacra<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_c37710418b73600e97b9c9f1ed6b75aa><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"T\u00f3rax PA\"  id='checkbox_4_c37710418b73600e97b9c9f1ed6b75aa' aria-label='T\u00f3rax PA' aria-invalid='false' aria-required=false> <span>T\u00f3rax PA<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_8fd1860588864dd4b25e501df873f027><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"T\u00f3rax PA y Lateral\"  id='checkbox_4_8fd1860588864dd4b25e501df873f027' aria-label='T\u00f3rax PA y Lateral' aria-invalid='false' aria-required=false> <span>T\u00f3rax PA y Lateral<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_34db22d4adc3b402b2a6e42e4aac9fc6><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"T\u00f3rax \u00d3seo (2P)\"  id='checkbox_4_34db22d4adc3b402b2a6e42e4aac9fc6' aria-label='T\u00f3rax \u00d3seo (2P)' aria-invalid='false' aria-required=false> <span>T\u00f3rax \u00d3seo (2P)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_d5f7b6b9f29cceb0f2dd9406c4d1e436><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pelvis centrada en pubis\"  id='checkbox_4_d5f7b6b9f29cceb0f2dd9406c4d1e436' aria-label='Pelvis centrada en pubis' aria-invalid='false' aria-required=false> <span>Pelvis centrada en pubis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_f060833d45715163db98df5b7f8ce7bd><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pelvis AP y &quot;rana&quot;\"  id='checkbox_4_f060833d45715163db98df5b7f8ce7bd' aria-label='Pelvis AP y &quot;rana&quot;' aria-invalid='false' aria-required=false> <span>Pelvis AP y \u00abrana\u00bb<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4_c1a5af427ea63b502a412bd80aa137b1><input  type=\"checkbox\" name=\"checkbox_4[]\" data-name=\"checkbox_4\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Radiopelvimetr\u00eda\"  id='checkbox_4_c1a5af427ea63b502a412bd80aa137b1' aria-label='Radiopelvimetr\u00eda' aria-invalid='false' aria-required=false> <span>Radiopelvimetr\u00eda<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Hombro Derecho\">Hombro Derecho<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_5b68c603edbc3bce655697f4deb6dcdb><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"12\" value=\"Hombro Derecho AP\"  id='checkbox_7_5b68c603edbc3bce655697f4deb6dcdb' aria-label='Hombro Derecho AP' aria-invalid='false' aria-required=false> <span>Hombro Derecho AP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_cf634493d053b13a5b12323b6fdc038a><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Hombro Derecho Rotaci\u00f3n Interna - Externa\"  id='checkbox_7_cf634493d053b13a5b12323b6fdc038a' aria-label='Hombro Derecho Rotaci\u00f3n Interna - Externa' aria-invalid='false' aria-required=false> <span>Hombro Derecho Rotaci\u00f3n Interna &#8211; Externa<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_0d8d840237a762db4d760bace27e7369><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Axial de Hombro Derecho\"  id='checkbox_7_0d8d840237a762db4d760bace27e7369' aria-label='Axial de Hombro Derecho' aria-invalid='false' aria-required=false> <span>Axial de Hombro Derecho<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_7_f740f7a31d67a7145f84ed048665d74c><input  type=\"checkbox\" name=\"checkbox_7[]\" data-name=\"checkbox_7\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Interescapulohumeral Derecha\"  id='checkbox_7_f740f7a31d67a7145f84ed048665d74c' aria-label='Interescapulohumeral Derecha' aria-invalid='false' aria-required=false> <span>Interescapulohumeral Derecha<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Hombro Iquierdo\">Hombro Iquierdo<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_cf3b7020baf7a2903637555901702905><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"13\" value=\"Hombro Izquierdo AP\"  id='checkbox_8_cf3b7020baf7a2903637555901702905' aria-label='Hombro Izquierdo AP' aria-invalid='false' aria-required=false> <span>Hombro Izquierdo AP<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_d0915d397c72c6796bb57c36ca07f2ae><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Hombro IzquierdoRotaci\u00f3n Interna - Externa\"  id='checkbox_8_d0915d397c72c6796bb57c36ca07f2ae' aria-label='Hombro IzquierdoRotaci\u00f3n Interna - Externa' aria-invalid='false' aria-required=false> <span>Hombro IzquierdoRotaci\u00f3n Interna &#8211; Externa<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_dc8086eb9a76540d56068035b6a0f500><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Axial de Hombro Izquierdo\"  id='checkbox_8_dc8086eb9a76540d56068035b6a0f500' aria-label='Axial de Hombro Izquierdo' aria-invalid='false' aria-required=false> <span>Axial de Hombro Izquierdo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_8_31ed0b899a81a7a99d81ea330ebf1bbe><input  type=\"checkbox\" name=\"checkbox_8[]\" data-name=\"checkbox_8\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Interescapulohumeral Izquierda\"  id='checkbox_8_31ed0b899a81a7a99d81ea330ebf1bbe' aria-label='Interescapulohumeral Izquierda' aria-invalid='false' aria-required=false> <span>Interescapulohumeral Izquierda<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Miembro Superior Derecho\">Miembro Superior Derecho<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_5492d3a7fe95bad8183fc939c2b2a2e0><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"14\" value=\"Brazo  derecho 2P\"  id='checkbox_9_5492d3a7fe95bad8183fc939c2b2a2e0' aria-label='Brazo  derecho 2P' aria-invalid='false' aria-required=false> <span>Brazo  derecho 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_85bca9d72d8aa2c42640fb7e26ec2191><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Codo derecho 2P\"  id='checkbox_9_85bca9d72d8aa2c42640fb7e26ec2191' aria-label='Codo derecho 2P' aria-invalid='false' aria-required=false> <span>Codo derecho 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_a8a830e5e0e8d7f6f64095d1e4074809><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mu\u00f1eca  derecha 2P\"  id='checkbox_9_a8a830e5e0e8d7f6f64095d1e4074809' aria-label='Mu\u00f1eca  derecha 2P' aria-invalid='false' aria-required=false> <span>Mu\u00f1eca  derecha 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9_648c4581262cebaf8e5391a3c0a5c775><input  type=\"checkbox\" name=\"checkbox_9[]\" data-name=\"checkbox_9\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mano derecha 2P\"  id='checkbox_9_648c4581262cebaf8e5391a3c0a5c775' aria-label='Mano derecha 2P' aria-invalid='false' aria-required=false> <span>Mano derecha 2P<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Miembro Superior Izquierdo\">Miembro Superior Izquierdo<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_8e848722875338d406f85903b16c36db><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"15\" value=\"Brazo  izquierdo 2P\"  id='checkbox_11_8e848722875338d406f85903b16c36db' aria-label='Brazo  izquierdo 2P' aria-invalid='false' aria-required=false> <span>Brazo  izquierdo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_58dc83f0859456d62fcef0e75187c66f><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Codo izquierdo 2P\"  id='checkbox_11_58dc83f0859456d62fcef0e75187c66f' aria-label='Codo izquierdo 2P' aria-invalid='false' aria-required=false> <span>Codo izquierdo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_cf83b0a23fa3c8a2380549aaed13fc44><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mu\u00f1eca  izquierda 2P\"  id='checkbox_11_cf83b0a23fa3c8a2380549aaed13fc44' aria-label='Mu\u00f1eca  izquierda 2P' aria-invalid='false' aria-required=false> <span>Mu\u00f1eca  izquierda 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_11_b84c277b510d7910f859e3331abfaf57><input  type=\"checkbox\" name=\"checkbox_11[]\" data-name=\"checkbox_11\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mano izquierda 2P\"  id='checkbox_11_b84c277b510d7910f859e3331abfaf57' aria-label='Mano izquierda 2P' aria-invalid='false' aria-required=false> <span>Mano izquierda 2P<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_7\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Miembro Inferior Derecho\">Miembro Inferior Derecho<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_2a17695858be44b77d36c238c0e9cfbb><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"16\" value=\"Cadera derecha 2P\"  id='checkbox_12_2a17695858be44b77d36c238c0e9cfbb' aria-label='Cadera derecha 2P' aria-invalid='false' aria-required=false> <span>Cadera derecha 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_d956c086f9344b7a6ea4eff892cc9727><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"F\u00e9mur derecho 2P\"  id='checkbox_12_d956c086f9344b7a6ea4eff892cc9727' aria-label='F\u00e9mur derecho 2P' aria-invalid='false' aria-required=false> <span>F\u00e9mur derecho 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_f40983b3191334b067f3756c5487c84c><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Rodilla derecha 2P\"  id='checkbox_12_f40983b3191334b067f3756c5487c84c' aria-label='Rodilla derecha 2P' aria-invalid='false' aria-required=false> <span>Rodilla derecha 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_3742bff1a57476b8d64ab4a29ebbf0cf><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Rodilla derecha 2P con apoyo\"  id='checkbox_12_3742bff1a57476b8d64ab4a29ebbf0cf' aria-label='Rodilla derecha 2P con apoyo' aria-invalid='false' aria-required=false> <span>Rodilla derecha 2P con apoyo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_98cb09677d72f88a42ff6d00fc2b0abd><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pierna derecha 2P\"  id='checkbox_12_98cb09677d72f88a42ff6d00fc2b0abd' aria-label='Pierna derecha 2P' aria-invalid='false' aria-required=false> <span>Pierna derecha 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_dfc865070b37dd66a3800f13ae50fdb4><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Tobillo derecho 2P\"  id='checkbox_12_dfc865070b37dd66a3800f13ae50fdb4' aria-label='Tobillo derecho 2P' aria-invalid='false' aria-required=false> <span>Tobillo derecho 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_af8779cae7ffdcd34733109d068f6239><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pie derecho 2P\"  id='checkbox_12_af8779cae7ffdcd34733109d068f6239' aria-label='Pie derecho 2P' aria-invalid='false' aria-required=false> <span>Pie derecho 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_2da772d5e7d21ec0159a201526f48958><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pie derecho 2P con apoyo\"  id='checkbox_12_2da772d5e7d21ec0159a201526f48958' aria-label='Pie derecho 2P con apoyo' aria-invalid='false' aria-required=false> <span>Pie derecho 2P con apoyo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_12_e221afc2546763e9f00d1df4504ad94f><input  type=\"checkbox\" name=\"checkbox_12[]\" data-name=\"checkbox_12\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Calc\u00e1neo derecho\"  id='checkbox_12_e221afc2546763e9f00d1df4504ad94f' aria-label='Calc\u00e1neo derecho' aria-invalid='false' aria-required=false> <span>Calc\u00e1neo derecho<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Miembro Inferior Izquierdo\">Miembro Inferior Izquierdo<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_87c32509a3323a54c041c2f740cdd542><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"17\" value=\"Cadera izquierda 2P\"  id='checkbox_13_87c32509a3323a54c041c2f740cdd542' aria-label='Cadera izquierda 2P' aria-invalid='false' aria-required=false> <span>Cadera izquierda 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_980052e53276260c1b64544adfe51ca2><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"F\u00e9mur izquierdo 2P\"  id='checkbox_13_980052e53276260c1b64544adfe51ca2' aria-label='F\u00e9mur izquierdo 2P' aria-invalid='false' aria-required=false> <span>F\u00e9mur izquierdo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_4f52f30385f9930c9bda2b83dc2a1adc><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Rodilla izquierda 2P\"  id='checkbox_13_4f52f30385f9930c9bda2b83dc2a1adc' aria-label='Rodilla izquierda 2P' aria-invalid='false' aria-required=false> <span>Rodilla izquierda 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_73775d5977562dbd86ba4a9e2b5185f1><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Rodilla izquierda 2P con apoyo\"  id='checkbox_13_73775d5977562dbd86ba4a9e2b5185f1' aria-label='Rodilla izquierda 2P con apoyo' aria-invalid='false' aria-required=false> <span>Rodilla izquierda 2P con apoyo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_3b50773ec64bd080b0e5a3dd1ecb4b0e><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pierna izquierda 2P\"  id='checkbox_13_3b50773ec64bd080b0e5a3dd1ecb4b0e' aria-label='Pierna izquierda 2P' aria-invalid='false' aria-required=false> <span>Pierna izquierda 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_6458718ebabb38e1d5af362c6f86d410><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Tobillo izquierdo 2P\"  id='checkbox_13_6458718ebabb38e1d5af362c6f86d410' aria-label='Tobillo izquierdo 2P' aria-invalid='false' aria-required=false> <span>Tobillo izquierdo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_f5040f317c6477efc3ba4411e9b215a9><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pie izquierdo 2P\"  id='checkbox_13_f5040f317c6477efc3ba4411e9b215a9' aria-label='Pie izquierdo 2P' aria-invalid='false' aria-required=false> <span>Pie izquierdo 2P<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_83c0e7e6def711a4d628ee782c38055a><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pie izquierdo 2P con apoyo\"  id='checkbox_13_83c0e7e6def711a4d628ee782c38055a' aria-label='Pie izquierdo 2P con apoyo' aria-invalid='false' aria-required=false> <span>Pie izquierdo 2P con apoyo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_13_d3252f784ef109a81fc05ead7b29299d><input  type=\"checkbox\" name=\"checkbox_13[]\" data-name=\"checkbox_13\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Calc\u00e1neo izquierdo\"  id='checkbox_13_d3252f784ef109a81fc05ead7b29299d' aria-label='Calc\u00e1neo izquierdo' aria-invalid='false' aria-required=false> <span>Calc\u00e1neo izquierdo<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-15_4\" ><p>&nbsp;<\/p>\n<p>&#8230;<\/p><\/div><div data-name=\"ff_cn_id_8\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ecosonograma (Ultrasonido)\">Ecosonograma (Ultrasonido)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_9281e1fb36c435fa4cd991ac9ee35841><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"18\" value=\"Abdomen\"  id='checkbox_14_9281e1fb36c435fa4cd991ac9ee35841' aria-label='Abdomen' aria-invalid='false' aria-required=false> <span>Abdomen<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_1d9294279698d1c15144d1fa4bb3dbdf><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Abdomen - Pelvis\"  id='checkbox_14_1d9294279698d1c15144d1fa4bb3dbdf' aria-label='Abdomen - Pelvis' aria-invalid='false' aria-required=false> <span>Abdomen &#8211; Pelvis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_2e72219f0b22fcdb9d62e81b52ad19ba><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Medici\u00f3n de Volumen PM\"  id='checkbox_14_2e72219f0b22fcdb9d62e81b52ad19ba' aria-label='Medici\u00f3n de Volumen PM' aria-invalid='false' aria-required=false> <span>Medici\u00f3n de Volumen PM<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_0bab3e6c912590592bcdf8404df7c859><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mamario\"  id='checkbox_14_0bab3e6c912590592bcdf8404df7c859' aria-label='Mamario' aria-invalid='false' aria-required=false> <span>Mamario<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_5f2b126972a70ba60241680fd5396bbd><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Prost\u00e1tico Suprap\u00fabico\"  id='checkbox_14_5f2b126972a70ba60241680fd5396bbd' aria-label='Prost\u00e1tico Suprap\u00fabico' aria-invalid='false' aria-required=false> <span>Prost\u00e1tico Suprap\u00fabico<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_ca0c7e88054e31fe0ded744fc69112e7><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Prost\u00e1tico Transrectal\"  id='checkbox_14_ca0c7e88054e31fe0ded744fc69112e7' aria-label='Prost\u00e1tico Transrectal' aria-invalid='false' aria-required=false> <span>Prost\u00e1tico Transrectal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_14488812c21976fcaa75dbbf14fdedc5><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"P\u00e9lvico\"  id='checkbox_14_14488812c21976fcaa75dbbf14fdedc5' aria-label='P\u00e9lvico' aria-invalid='false' aria-required=false> <span>P\u00e9lvico<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_6f9bf2eda2233eced04cbe03583a0101><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Renal\"  id='checkbox_14_6f9bf2eda2233eced04cbe03583a0101' aria-label='Renal' aria-invalid='false' aria-required=false> <span>Renal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_725f28f71bc33a6740fa3381504ad4ed><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Partes Blandas  (observaciones)\"  id='checkbox_14_725f28f71bc33a6740fa3381504ad4ed' aria-label='Partes Blandas  (observaciones)' aria-invalid='false' aria-required=false> <span>Partes Blandas  (observaciones)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_2fcfaeccb43b626385e2b0639709a673><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Tiroides\"  id='checkbox_14_2fcfaeccb43b626385e2b0639709a673' aria-label='Tiroides' aria-invalid='false' aria-required=false> <span>Tiroides<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_14_c2b4cdbcfe2b49715bede89b6ac73055><input  type=\"checkbox\" name=\"checkbox_14[]\" data-name=\"checkbox_14\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Transvaginal\"  id='checkbox_14_c2b4cdbcfe2b49715bede89b6ac73055' aria-label='Transvaginal' aria-invalid='false' aria-required=false> <span>Transvaginal<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Ecosonograma Doppler\">Ecosonograma Doppler<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_b547447f5d54303766980ef93179dfce><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"19\" value=\"Abdomen\"  id='checkbox_15_b547447f5d54303766980ef93179dfce' aria-label='Abdomen' aria-invalid='false' aria-required=false> <span>Abdomen<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_7339720333f107e20132ba4b3ffb8a31><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Carotideo-vertebral\"  id='checkbox_15_7339720333f107e20132ba4b3ffb8a31' aria-label='Carotideo-vertebral' aria-invalid='false' aria-required=false> <span>Carotideo-vertebral<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_62f6726d16c4f613f77929586faf45d8><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Mamario\"  id='checkbox_15_62f6726d16c4f613f77929586faf45d8' aria-label='Mamario' aria-invalid='false' aria-required=false> <span>Mamario<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_0370e75fdb0c24023322a84e623ded8d><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Pelvis\"  id='checkbox_15_0370e75fdb0c24023322a84e623ded8d' aria-label='Pelvis' aria-invalid='false' aria-required=false> <span>Pelvis<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_1cc2d692c0967684c8709d2e145c590b><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Renal\"  id='checkbox_15_1cc2d692c0967684c8709d2e145c590b' aria-label='Renal' aria-invalid='false' aria-required=false> <span>Renal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_c208edc214815a14a9c84c34ffedf28a><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Testicular - Escrotal\"  id='checkbox_15_c208edc214815a14a9c84c34ffedf28a' aria-label='Testicular - Escrotal' aria-invalid='false' aria-required=false> <span>Testicular &#8211; Escrotal<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_b00d1b7e885b16a260ad540fdb633d60><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Tiroides\"  id='checkbox_15_b00d1b7e885b16a260ad540fdb633d60' aria-label='Tiroides' aria-invalid='false' aria-required=false> <span>Tiroides<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_ef3995d1000781b43a5cd24916420447><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Arterial Miembro Inferior derecho \"  id='checkbox_15_ef3995d1000781b43a5cd24916420447' aria-label='Arterial Miembro Inferior derecho' aria-invalid='false' aria-required=false> <span>Arterial Miembro Inferior derecho <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_055f5f6d57ddc35607b5f9340dcbf761><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Venoso Miembro Inferior derecho \"  id='checkbox_15_055f5f6d57ddc35607b5f9340dcbf761' aria-label='Venoso Miembro Inferior derecho' aria-invalid='false' aria-required=false> <span>Venoso Miembro Inferior derecho <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_2820de6f0d05b13d60eb3c3d57397004><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Arterial Miembro Inferior izquierdo\"  id='checkbox_15_2820de6f0d05b13d60eb3c3d57397004' aria-label='Arterial Miembro Inferior izquierdo' aria-invalid='false' aria-required=false> <span>Arterial Miembro Inferior izquierdo<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_15_8ac2fb3d97c4f9b11fa8143c7c8b3262><input  type=\"checkbox\" name=\"checkbox_15[]\" data-name=\"checkbox_15\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Venoso Miembro Inferior izquierdo\"  id='checkbox_15_8ac2fb3d97c4f9b11fa8143c7c8b3262' aria-label='Venoso Miembro Inferior izquierdo' aria-invalid='false' aria-required=false> <span>Venoso Miembro Inferior izquierdo<\/span><\/label><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_9\"  class='ff-t-container ff-column-container ff_columns_total_2 '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label   aria-label=\"Densitometr\u00eda \u00f3sea\">Densitometr\u00eda \u00f3sea<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_d09490bf65de30c3e8fac252cbe7250f><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"20\" value=\"DMO Pesquisa (Columna AP y 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class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Densitometr\u00eda \u00f3sea de Cuerpo Entero\"  id='checkbox_1_1e33fcc0c5d4757259e316cdc915cc7b' aria-label='Densitometr\u00eda \u00f3sea de Cuerpo Entero' aria-invalid='false' aria-required=false> <span>Densitometr\u00eda \u00f3sea de Cuerpo Entero<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_48d917f79bf6bf77339f9a50b9cadbe8><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" tabindex=\"-1\" value=\"Densitometr\u00eda de Mu\u00f1eca izquierda\"  id='checkbox_1_48d917f79bf6bf77339f9a50b9cadbe8' aria-label='Densitometr\u00eda de Mu\u00f1eca izquierda' aria-invalid='false' aria-required=false> <span>Densitometr\u00eda de Mu\u00f1eca izquierda<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_15_input_text' id='label_ff_15_input_text' aria-label=\"Otros estudios\">Otros estudios<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" tabindex=\"21\" id=\"ff_15_input_text\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_15_input_text_1' id='label_ff_15_input_text_1' aria-label=\"Impresi\u00f3n Diagn\u00f3stica\/Observaciones\">Impresi\u00f3n Diagn\u00f3stica\/Observaciones<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" tabindex=\"22\" id=\"ff_15_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-15_5\" ><h3 class='ff-el-section-title'><\/h3><div class='ff-section_break_desk'><\/div><hr \/><\/div><div class='ff-el-group ff-text-center ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style wpf_has_custom_css\" tabindex=\"23\"  aria-label=\"Enviar Solicitud de Estudios\">Enviar Solicitud de Estudios<\/button><\/div><\/fieldset><\/form><div id='fluentform_15_errors' class='ff-errors-in-stack ff_form_instance_15_1 ff-form-loading_errors ff_form_instance_15_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_15_1 = 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