{"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=\"Contact\">\n                    Contact                <\/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_e54d9d44f466f698bd3460d8cf2fb216><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_e54d9d44f466f698bd3460d8cf2fb216' 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_04da98b9341956ff5c218ccbb8f003ad><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_04da98b9341956ff5c218ccbb8f003ad' 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_ded667160b2289a49c1ac39c3787b91b><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_ded667160b2289a49c1ac39c3787b91b' 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_fa399ef7a8c4c914a8873215cb2600a6><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_fa399ef7a8c4c914a8873215cb2600a6' 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_4c5b3b9533fe57d34f7f16ed5fc8bd14><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_4c5b3b9533fe57d34f7f16ed5fc8bd14' 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_e4555f64b54e79ad1ed032a613fa2bd0><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_e4555f64b54e79ad1ed032a613fa2bd0' 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_a7bcc75a3294ea56ee2d61222f007010><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_a7bcc75a3294ea56ee2d61222f007010' 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_d6d442ab781dae1f643b645d31232feb><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_d6d442ab781dae1f643b645d31232feb' 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_460f82739e6d4cf6b858dfc424c983db><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_460f82739e6d4cf6b858dfc424c983db' 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_fe30020baa0e78261b3588ceeb03dfda><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_fe30020baa0e78261b3588ceeb03dfda' 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_7e1f9166d9e1f5e59a211b18380a156d><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_7e1f9166d9e1f5e59a211b18380a156d' 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_5557462d702b6f0d026acb2f1bf498b3><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_5557462d702b6f0d026acb2f1bf498b3' 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_c4710581b79204d7e831cc4b1e10f3dc><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_c4710581b79204d7e831cc4b1e10f3dc' 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_f57a394657ed5963923b455e3aa0895c><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_f57a394657ed5963923b455e3aa0895c' 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_b0fc2fdf37ec95324ee55272b784c585><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_b0fc2fdf37ec95324ee55272b784c585' 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_e2c4c9b9fa79587c26ea5bac39297860><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_e2c4c9b9fa79587c26ea5bac39297860' 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_4c6dee01a1bed890d02a3d6c499e583b><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_4c6dee01a1bed890d02a3d6c499e583b' 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_21efc083c224721a10fb2e4b624422c5><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_21efc083c224721a10fb2e4b624422c5' 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_0937956d8ebc6985ef351291a273e854><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_0937956d8ebc6985ef351291a273e854' 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_5ea212a77d4ae1d0b7f468d7c2104937><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_5ea212a77d4ae1d0b7f468d7c2104937' 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_7d57f6b21ca3ab397879117434e9cb01><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_7d57f6b21ca3ab397879117434e9cb01' 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_7906fc66e3a080b00cc776620de31e6d><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_7906fc66e3a080b00cc776620de31e6d' 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_2f7a135bf129427e0f49f55f5cf786cb><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_2f7a135bf129427e0f49f55f5cf786cb' 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_b53b5e761334ae01f06c2c6ef92882a3><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_b53b5e761334ae01f06c2c6ef92882a3' 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_27b987d4638250714b08a65c3832b6c9><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_27b987d4638250714b08a65c3832b6c9' 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_7f4065cb047178ea17cc3d68e3a9850c><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_7f4065cb047178ea17cc3d68e3a9850c' 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_5210795772b9a2db3e7302b1ca54129d><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_5210795772b9a2db3e7302b1ca54129d' 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_73f44908686533bfc879324ff3590920><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_73f44908686533bfc879324ff3590920' 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_62ffee9571eeb3592e7378d0fa7f26fc><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_62ffee9571eeb3592e7378d0fa7f26fc' 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_f44ae888e5963812340c31623f9c7c4e><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_f44ae888e5963812340c31623f9c7c4e' 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_53627c2d09bc6408d776ef178944e904><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_53627c2d09bc6408d776ef178944e904' 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_5b85dc1ed92bc8c39003f816f9591ddf><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_5b85dc1ed92bc8c39003f816f9591ddf' 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_271376a8f4e17c5d7e56fa12c54b616b><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_271376a8f4e17c5d7e56fa12c54b616b' 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_a559ac0d4d7101bfbb315f7a0086e841><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_a559ac0d4d7101bfbb315f7a0086e841' 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_dacebb0742689cbd43dd7ef5cedf1e7e><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_dacebb0742689cbd43dd7ef5cedf1e7e' 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_8ac42b8ec253e0b731679bc8d165e612><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_8ac42b8ec253e0b731679bc8d165e612' 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_2e6510644ec89f9404cbe3d2b40b92cb><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_2e6510644ec89f9404cbe3d2b40b92cb' 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_8a1266e38abb41fe614c39f3fef0fb42><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_8a1266e38abb41fe614c39f3fef0fb42' 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_7abf8a131df4b98464eb9fa062674a7f><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_7abf8a131df4b98464eb9fa062674a7f' 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_4a2e9b8fb806093261583123da213842><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_4a2e9b8fb806093261583123da213842' 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_9d055caec175b486e3b43e701b95c5f8><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_9d055caec175b486e3b43e701b95c5f8' 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_6d0b6d88117e6f7796c810abb9a8dd92><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_6d0b6d88117e6f7796c810abb9a8dd92' 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_71cd315c8a3994bf3bc150c0825dbff9><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_71cd315c8a3994bf3bc150c0825dbff9' 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_9fa295aa360009c8ed06890031b9d760><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_9fa295aa360009c8ed06890031b9d760' 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_56ed3b8d512fac0e6d0f56e33d17b8d4><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_56ed3b8d512fac0e6d0f56e33d17b8d4' 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_4322e62cda2cfe8f32d7ab67db67eebb><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_4322e62cda2cfe8f32d7ab67db67eebb' 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_84a694a32eae783a52d0dea5b4ef971c><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_84a694a32eae783a52d0dea5b4ef971c' 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_4fe4efc24783caa1406c0480d330f721><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_4fe4efc24783caa1406c0480d330f721' 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_736d828bf47150e12b28aa4fe2500452><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_736d828bf47150e12b28aa4fe2500452' 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_01cf715b4cf2a1b46b06be02b28449e2><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_01cf715b4cf2a1b46b06be02b28449e2' 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_1968a465d203861d76831cab0467b0c1><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_1968a465d203861d76831cab0467b0c1' 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_0a9e1ff2f71d882eabf88be5b6a3223d><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_0a9e1ff2f71d882eabf88be5b6a3223d' 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_9809590ac95646b5d0907429d1b7afef><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_9809590ac95646b5d0907429d1b7afef' 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_f55753c7348e4d0a555182848a35954c><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_f55753c7348e4d0a555182848a35954c' 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_72e3ed4b72458f0070e83501b136e142><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_72e3ed4b72458f0070e83501b136e142' 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_5ceb186e296fb0688bf9012a4dcb647b><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_5ceb186e296fb0688bf9012a4dcb647b' 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_6462e9a3598e1d9ed57440250f9bfa26><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_6462e9a3598e1d9ed57440250f9bfa26' 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_5902566d1745fb2163df227c159a2485><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_5902566d1745fb2163df227c159a2485' 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_9839c58f89d236784906404e150acbde><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_9839c58f89d236784906404e150acbde' 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_976c080b5d4ec393a4279376593f7f96><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_976c080b5d4ec393a4279376593f7f96' 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_864de66e4927890104ef9c82024a288f><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_864de66e4927890104ef9c82024a288f' 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_31fe7fc4a32fe77c1b888567620dfc0e><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_31fe7fc4a32fe77c1b888567620dfc0e' 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_76c0675b94598c1d1446960fc8c6fde3><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_76c0675b94598c1d1446960fc8c6fde3' 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_d8f48f889df6fe5b2730a0f32e224535><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_d8f48f889df6fe5b2730a0f32e224535' 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_c02d2d323290423778393fb188c327c9><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_c02d2d323290423778393fb188c327c9' 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_db3cd04872cf0245c9c1c61b706f61d7><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_db3cd04872cf0245c9c1c61b706f61d7' 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_aadcfa4a9c80469376f9f11c6365a6aa><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_aadcfa4a9c80469376f9f11c6365a6aa' 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_953b892dfea531296ff6ed9cae4cf41d><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_953b892dfea531296ff6ed9cae4cf41d' 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_9094210e0c79b29c22fce100e477b6eb><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_9094210e0c79b29c22fce100e477b6eb' 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_68c967d7e2eca413c31a3440c546c7c7><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_68c967d7e2eca413c31a3440c546c7c7' 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_fc7214923004b328dd190c14ef886a3b><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_fc7214923004b328dd190c14ef886a3b' 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_061aa96357deb789d7fca50fb69d1deb><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_061aa96357deb789d7fca50fb69d1deb' 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_137e0352086b0eee385e13b293f6db5f><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_137e0352086b0eee385e13b293f6db5f' 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_27eeaf7094a83155522286dd6857b498><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_27eeaf7094a83155522286dd6857b498' 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_2836e928bb59998948473122f414884d><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_2836e928bb59998948473122f414884d' 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_90fbca3be602012d5242d2cee8ce0c9c><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_90fbca3be602012d5242d2cee8ce0c9c' 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_fdb5aee258b7389b051a1a37ad8d5c1f><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_fdb5aee258b7389b051a1a37ad8d5c1f' 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_02bcc5c3401904087056b971b3e3606a><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_02bcc5c3401904087056b971b3e3606a' 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_b43d2d934e2dbf5d2b2838998f036a4d><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_b43d2d934e2dbf5d2b2838998f036a4d' 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_fa2e807f78198a9ff6925c2d6b0f5c1f><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_fa2e807f78198a9ff6925c2d6b0f5c1f' 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_20aaa2c15dab349338e10b319fc900d6><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_20aaa2c15dab349338e10b319fc900d6' 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_2779c6e018094d6f0d24836c086037bc><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_2779c6e018094d6f0d24836c086037bc' 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_352ce12d3654d7721dd782ccfe370650><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_352ce12d3654d7721dd782ccfe370650' 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_14790a7fa77bdd78e2035acdca04514f><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_a55f7aa221db603fbab84b41d749e4b9' 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_29586b4756c9a496d7bcf3805430caee><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_29586b4756c9a496d7bcf3805430caee' 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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