{"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=\"Newsletter\">\n                    Newsletter                <\/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=\"b0077b2d95\" \/><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=\"20\/04\/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_126f835fcfac759702941b5e563bab7a><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_126f835fcfac759702941b5e563bab7a' 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_7a4156685df869aa77d22d19410567d6><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_7a4156685df869aa77d22d19410567d6' 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_4dcd6f1c5b4022b03d551df86d8ce8cf><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_4dcd6f1c5b4022b03d551df86d8ce8cf' 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_7c33bc901663aa67184830a3dea3f5d6><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_7c33bc901663aa67184830a3dea3f5d6' 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_b587e75caaaa9c6b47cdb3fdbd954b73><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_b587e75caaaa9c6b47cdb3fdbd954b73' 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_197a6594fef1761d0ddd5935c2b4fcd2><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_197a6594fef1761d0ddd5935c2b4fcd2' 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_62246f8283e5954b550068962dc75bac><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_62246f8283e5954b550068962dc75bac' 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_1d00538c77ebbb3a68c263d430510b5b><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_1d00538c77ebbb3a68c263d430510b5b' 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_f7bcdb7850849520c6a8545f1cbf78ef><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_f7bcdb7850849520c6a8545f1cbf78ef' 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_6db4f5f822465a54c2fc0a21c42b1065><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_6db4f5f822465a54c2fc0a21c42b1065' 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_b8734b3e471ed46d32413faf7a98fb1d><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_b8734b3e471ed46d32413faf7a98fb1d' 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_74bb1840a060cc882adb0a13e7cef324><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_74bb1840a060cc882adb0a13e7cef324' 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_71a5818b0acfc42defa9d18c99c43588><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_71a5818b0acfc42defa9d18c99c43588' 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_f90043757aae529bef43c5ad3a81d011><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_f90043757aae529bef43c5ad3a81d011' 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_99444b8937ffe83d834eaeb128243b09><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_99444b8937ffe83d834eaeb128243b09' 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_6f30569ec24c6d2c4307ab6417c5e211><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_6f30569ec24c6d2c4307ab6417c5e211' 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_28034dd99828003272daec51e05771b8><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_28034dd99828003272daec51e05771b8' 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_7968b1a39147d72d7b24682e8e327a27><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_7968b1a39147d72d7b24682e8e327a27' 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_91716f639616d900a387d40502dbcfb7><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_91716f639616d900a387d40502dbcfb7' 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_976b106e71e00b190b3ee558d919be50><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_976b106e71e00b190b3ee558d919be50' 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_fdc16a4d98fa7b1edc88e4e934f0d4ec><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_fdc16a4d98fa7b1edc88e4e934f0d4ec' 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_45dc44eb104acf475a2dc3514775eed7><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_45dc44eb104acf475a2dc3514775eed7' 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_ce2b32c19003a68c570e2cac9142cecf><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_ce2b32c19003a68c570e2cac9142cecf' 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_393538afbf4613e2aea09e9871d5bb47><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_393538afbf4613e2aea09e9871d5bb47' 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_435a9501a75b169ef914de8f3cc68309><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_435a9501a75b169ef914de8f3cc68309' 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_1c7e7135f2ff239ed27212ffbcbfc3a1><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_1c7e7135f2ff239ed27212ffbcbfc3a1' 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_214b4e2c4429164a3739e3c584e96172><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_214b4e2c4429164a3739e3c584e96172' 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_cb24fee83c7a45ce1f3ab9df197a63da><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_cb24fee83c7a45ce1f3ab9df197a63da' 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_b06164fa8cf6256d56ea28c0ff6ad193><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_b06164fa8cf6256d56ea28c0ff6ad193' 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_4e0530e4b32cb00406180a274ed67286><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_4e0530e4b32cb00406180a274ed67286' 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_3c24aaf8d08de87666efe22e0e0f89d0><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_3c24aaf8d08de87666efe22e0e0f89d0' 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_e82cecd7af0a4b5ed83e702841e554ca><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_e82cecd7af0a4b5ed83e702841e554ca' 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_6201e249e441e489ca9777ec269092c0><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_6201e249e441e489ca9777ec269092c0' 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_fd82640c745a306f8f697eabfbf85fbb><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_fd82640c745a306f8f697eabfbf85fbb' 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_687b255ae58001fee0e5d110c4b2c3ad><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_687b255ae58001fee0e5d110c4b2c3ad' 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_37df05310f68c390e533e17922c87951><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_37df05310f68c390e533e17922c87951' 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_912fe2c5305ef97dfee28aba996e1547><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_912fe2c5305ef97dfee28aba996e1547' 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_7754a5cb777e7b051166cdd04e693364><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_7754a5cb777e7b051166cdd04e693364' 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_b0a7264b81bfeaa31510c3524237e351><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_b0a7264b81bfeaa31510c3524237e351' 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_661096b2ef8348bce65fd5e635d3c8ec><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_661096b2ef8348bce65fd5e635d3c8ec' 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_244cfe1380e9821a7cb7c8f8e5cb0426><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_244cfe1380e9821a7cb7c8f8e5cb0426' 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_49c23330abdb8ed3b09d201aab7b7ee5><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_49c23330abdb8ed3b09d201aab7b7ee5' 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_83422641e40d7f9d699fd239871f345a><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_83422641e40d7f9d699fd239871f345a' 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_b9f1a7887d76db5c13bedc243102d121><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_b9f1a7887d76db5c13bedc243102d121' 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_2de758060ee40b41a4e094af397f25bf><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_2de758060ee40b41a4e094af397f25bf' 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_3f45e3ca1ff466e72dfdd734870cc224><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_3f45e3ca1ff466e72dfdd734870cc224' 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_e70fad0a4593e0962b617b97fbde11c3><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_e70fad0a4593e0962b617b97fbde11c3' 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_1f369d72c3039d30ab587621bbb593a4><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_1f369d72c3039d30ab587621bbb593a4' 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_f73b8e19911a9213d06b108e22a39c4f><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_f73b8e19911a9213d06b108e22a39c4f' 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_2a3b501f35a903d73f505d37ceb0ffa9><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_2a3b501f35a903d73f505d37ceb0ffa9' 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_efddf8bb47f85790b6f71dac26b72950><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_efddf8bb47f85790b6f71dac26b72950' 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_0cf1019aabe3afe96af34695736c658f><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_0cf1019aabe3afe96af34695736c658f' 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_88af0e1f85752ba9115e7a61e191465b><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_88af0e1f85752ba9115e7a61e191465b' 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_74f9b8faa957e0ef0bf79860ef84058c><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_74f9b8faa957e0ef0bf79860ef84058c' 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_5b4cc9e8df6e36e4a6b46a0d30f9936a><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_5b4cc9e8df6e36e4a6b46a0d30f9936a' 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_37b5c633cb05bed49b723033c84e3859><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_37b5c633cb05bed49b723033c84e3859' 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_8879366f83af857266773f15a3f978ac><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_8879366f83af857266773f15a3f978ac' 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_0f348f5a7e241fe9e749d3e927205886><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_0f348f5a7e241fe9e749d3e927205886' 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_0b38abf6216519b2e29541e894932ccd><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_0b38abf6216519b2e29541e894932ccd' 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_8b6dbd1635196aa485a555af90b63c32><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_8b6dbd1635196aa485a555af90b63c32' 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_86df744b1c1b6c19dd5df614ce455e8b><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_86df744b1c1b6c19dd5df614ce455e8b' 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_0e2ecae00897c4e5c65400c7bd584c70><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_0e2ecae00897c4e5c65400c7bd584c70' 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_a49172af31f6a6cfb5db3a972fb48fd2><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_a49172af31f6a6cfb5db3a972fb48fd2' 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_cdd89f324d08bb81c3cd1a3517dab537><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_cdd89f324d08bb81c3cd1a3517dab537' 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_5a295e9c1557fd727caacfc8285e3bb0><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_5a295e9c1557fd727caacfc8285e3bb0' 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_b1befafdaeca04936aa00a3d47d73721><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_b1befafdaeca04936aa00a3d47d73721' 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_6854e99dcd7cd86895ed07d43ca36ad1><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_6854e99dcd7cd86895ed07d43ca36ad1' 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_491d573b466e43e89c86b33bbeb5176d><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_491d573b466e43e89c86b33bbeb5176d' 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_4474d9e6009afb37cce58873d43774de><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_4474d9e6009afb37cce58873d43774de' 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_4ae81628f6f7bdfb87252798ed38b320><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_4ae81628f6f7bdfb87252798ed38b320' 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_89bcc618723fc8a6fbf23f71c9af97e3><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_89bcc618723fc8a6fbf23f71c9af97e3' 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_96ac6e6ad68e02a72e71febabfa0e84b><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_96ac6e6ad68e02a72e71febabfa0e84b' 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_326ccacc9eb24a795d9521651db60f7e><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_326ccacc9eb24a795d9521651db60f7e' 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_ac11eef2530392d6f32d6defed6907d2><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_ac11eef2530392d6f32d6defed6907d2' 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_0cac65c5b8029e6682691a48d91d5c9f><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_0cac65c5b8029e6682691a48d91d5c9f' 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_882b59ff98c8cdc4f8368fdf15e285c4><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_882b59ff98c8cdc4f8368fdf15e285c4' 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_c6460e0c7e8efa9e643ade99b6713af4><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_c6460e0c7e8efa9e643ade99b6713af4' 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_74da15a763574b62f129c6df32472e6d><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_74da15a763574b62f129c6df32472e6d' 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_eb0e67883b92784cb5d2a45b482af829><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_eb0e67883b92784cb5d2a45b482af829' 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_9063c18631df7cc57e925a82ad8ef407><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_9063c18631df7cc57e925a82ad8ef407' 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_bf79d77f3b9e546eb8f88ffa1cf6cff5><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_bf79d77f3b9e546eb8f88ffa1cf6cff5' 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_230cfce1fffc43dfa15ffdb1d6dd851d><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_230cfce1fffc43dfa15ffdb1d6dd851d' 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_2b13d11df32120cd72d65c2f41560a7b><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_2b13d11df32120cd72d65c2f41560a7b' 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_7e6d18f1bfd2372cb12a54ab1a1ca56e><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_8027c3387e3aa152729d46a3c2837e05' 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_bf0c99bcded290cac8096753ac2d93ac><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_bf0c99bcded290cac8096753ac2d93ac' 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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