{"id":371405,"date":"2024-07-17T09:14:20","date_gmt":"2024-07-17T09:14:20","guid":{"rendered":"https:\/\/centromedicomanzanera.com\/formulario-es\/"},"modified":"2024-10-09T09:34:14","modified_gmt":"2024-10-09T09:34:14","slug":"formulario-en","status":"publish","type":"page","link":"https:\/\/centromedicomanzanera.com\/en\/formulario-en\/","title":{"rendered":"Formulario EN"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;0px||||false|false&#8221; custom_padding=&#8221;0px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; max_width=&#8221;800px&#8221; custom_padding=&#8221;0px||||false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.26.1&#8243; _module_preset=&#8221;default&#8221; 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data-token-time=\"1776790784\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-371605-field_47-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-type=\"hidden\" data-field-id=\"47\"><input type=\"hidden\" id=\"wpforms-371605-field_47\" name=\"wpforms[fields][47]\" value=\"21\/04\/2026\"><\/div><div id=\"wpforms-371605-field_56-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"56\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-371605-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-371605-field_0\">NAME <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-371605-field_0\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][0]\" aria-errormessage=\"wpforms-371605-field_0-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-371605-field_43-container\" class=\"wpforms-field wpforms-field-name\" data-field-type=\"name\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-371605-field_43\">SURNAME<\/label><input type=\"text\" id=\"wpforms-371605-field_43\" class=\"wpforms-field-large\" name=\"wpforms[fields][43]\" aria-errormessage=\"wpforms-371605-field_43-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-371605-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-type=\"email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-371605-field_1\">E-MAIL <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-371605-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" aria-errormessage=\"wpforms-371605-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-371605-field_19-container\" class=\"wpforms-field wpforms-field-phone\" data-field-type=\"phone\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-371605-field_19\">PHONE NUMBER<\/label><input type=\"tel\" id=\"wpforms-371605-field_19\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][19]\" aria-label=\"PHONE NUMBER\" aria-errormessage=\"wpforms-371605-field_19-error\" ><\/div><\/div><\/div><\/div><\/div><div id=\"wpforms-371605-field_14-container\" class=\"wpforms-field wpforms-field-layout\" data-field-type=\"layout\" data-field-id=\"14\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-371605-field_18-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-type=\"select\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-371605-field_18\">COUNTRY  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-371605-field_18\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][18]\" required=\"required\"><option value=\"GB United Kingdom\" >GB United Kingdom<\/option><option value=\"AF Afghanistan\" >AF Afghanistan<\/option><option value=\"AX \u00c5land Islands\" >AX \u00c5land Islands<\/option><option value=\"AL Albania\" >AL Albania<\/option><option value=\"DZ Algeria\" >DZ Algeria<\/option><option value=\"AS American Samoa\" >AS American Samoa<\/option><option value=\"AD Andorra\" >AD Andorra<\/option><option value=\"AO Angola\" >AO Angola<\/option><option value=\"AI Anguilla\" >AI Anguilla<\/option><option value=\"AQ Antarctica\" >AQ Antarctica<\/option><option value=\"AG Antigua &amp; Barbuda\" >AG Antigua &amp; Barbuda<\/option><option value=\"AR Argentina\" >AR Argentina<\/option><option value=\"AM Armenia\" >AM Armenia<\/option><option value=\"AW Aruba\" >AW Aruba<\/option><option value=\"AU Australia\" >AU Australia<\/option><option value=\"AT Austria\" >AT Austria<\/option><option value=\"AZ Azerbaijan\" >AZ Azerbaijan<\/option><option value=\"BS Bahamas\" >BS Bahamas<\/option><option value=\"BH Bahrain\" >BH Bahrain<\/option><option value=\"BD Bangladesh\" >BD Bangladesh<\/option><option value=\"BB Barbados\" >BB Barbados<\/option><option value=\"BY Belarus\" >BY Belarus<\/option><option value=\"BE Belgium\" >BE Belgium<\/option><option value=\"BZ Belize\" >BZ Belize<\/option><option value=\"BJ Benin\" >BJ Benin<\/option><option value=\"BM Bermuda\" >BM Bermuda<\/option><option value=\"BT Bhutan\" >BT Bhutan<\/option><option value=\"BO Bolivia\" >BO Bolivia<\/option><option value=\"BA Bosnia &amp; Herzegovina\" >BA Bosnia &amp; Herzegovina<\/option><option value=\"BW Botswana\" >BW Botswana<\/option><option value=\"BV Bouvet Island\" >BV Bouvet Island<\/option><option value=\"BR Brazil\" >BR Brazil<\/option><option value=\"IO British Indian Ocean Territory\" >IO British Indian Ocean Territory<\/option><option value=\"VG British Virgin Islands\" >VG British Virgin Islands<\/option><option value=\"BN Brunei\" >BN Brunei<\/option><option value=\"BG Bulgaria\" >BG Bulgaria<\/option><option value=\"BF Burkina Faso\" >BF Burkina Faso<\/option><option value=\"BI Burundi\" >BI Burundi<\/option><option value=\"KH Cambodia\" >KH Cambodia<\/option><option value=\"CM Cameroon\" >CM Cameroon<\/option><option value=\"CA Canada\" >CA Canada<\/option><option value=\"CV Cape Verde\" >CV Cape Verde<\/option><option value=\"BQ Caribbean Netherlands\" >BQ Caribbean Netherlands<\/option><option value=\"KY Cayman Islands\" >KY Cayman Islands<\/option><option value=\"CF Central African Republic\" >CF Central African Republic<\/option><option value=\"TD Chad\" >TD Chad<\/option><option value=\"CL Chile\" >CL Chile<\/option><option value=\"CN China\" >CN China<\/option><option value=\"CX Christmas Island\" >CX Christmas Island<\/option><option value=\"CC Cocos (Keeling) Islands\" >CC Cocos (Keeling) Islands<\/option><option value=\"CO Colombia\" >CO Colombia<\/option><option value=\"KM Comoros\" >KM Comoros<\/option><option value=\"CG Congo - Brazzaville\" >CG Congo - Brazzaville<\/option><option value=\"CD Congo - Kinshasa\" >CD Congo - Kinshasa<\/option><option value=\"CK Cook Islands\" >CK Cook Islands<\/option><option value=\"CR Costa Rica\" >CR Costa Rica<\/option><option value=\"CI C\u00f4te d\u2019Ivoire\" >CI C\u00f4te d\u2019Ivoire<\/option><option value=\"HR Croatia\" >HR Croatia<\/option><option value=\"CU Cuba\" >CU Cuba<\/option><option value=\"CW Cura\u00e7ao\" >CW Cura\u00e7ao<\/option><option value=\"CY Cyprus\" >CY Cyprus<\/option><option value=\"CZ Czechia\" >CZ Czechia<\/option><option value=\"DK Denmark\" >DK Denmark<\/option><option value=\"DJ Djibouti\" >DJ Djibouti<\/option><option value=\"DM Dominica\" >DM Dominica<\/option><option value=\"DO Dominican Republic\" >DO Dominican Republic<\/option><option value=\"EC Ecuador\" >EC Ecuador<\/option><option value=\"EG Egypt\" >EG Egypt<\/option><option value=\"SV El Salvador\" >SV El Salvador<\/option><option value=\"GQ Equatorial Guinea\" >GQ Equatorial Guinea<\/option><option value=\"ER Eritrea\" >ER Eritrea<\/option><option value=\"EE Estonia\" >EE Estonia<\/option><option value=\"SZ Eswatini\" >SZ Eswatini<\/option><option value=\"ET Ethiopia\" >ET Ethiopia<\/option><option value=\"FK Falkland Islands\" >FK Falkland Islands<\/option><option value=\"FO Faroe Islands\" >FO Faroe Islands<\/option><option value=\"FJ Fiji\" >FJ Fiji<\/option><option value=\"FI Finland\" >FI Finland<\/option><option value=\"FR France\" >FR France<\/option><option value=\"GF French Guiana\" >GF French Guiana<\/option><option value=\"PF French Polynesia\" >PF French Polynesia<\/option><option value=\"TF French Southern Territories\" >TF French Southern Territories<\/option><option value=\"GA Gabon\" >GA Gabon<\/option><option value=\"GM Gambia\" >GM Gambia<\/option><option value=\"GE Georgia\" >GE Georgia<\/option><option value=\"DE Germany\" >DE Germany<\/option><option value=\"GH Ghana\" >GH Ghana<\/option><option value=\"GI Gibraltar\" >GI Gibraltar<\/option><option value=\"GR Greece\" >GR Greece<\/option><option value=\"GL Greenland\" >GL Greenland<\/option><option value=\"GD Grenada\" >GD Grenada<\/option><option value=\"GP Guadeloupe\" >GP Guadeloupe<\/option><option value=\"GU Guam\" >GU Guam<\/option><option value=\"GT Guatemala\" >GT Guatemala<\/option><option value=\"GG Guernsey\" >GG Guernsey<\/option><option value=\"GN Guinea\" >GN Guinea<\/option><option value=\"GW Guinea-Bissau\" >GW Guinea-Bissau<\/option><option value=\"GY Guyana\" >GY Guyana<\/option><option value=\"HT Haiti\" >HT Haiti<\/option><option value=\"HM Heard &amp; McDonald Islands\" >HM Heard &amp; McDonald Islands<\/option><option value=\"HN Honduras\" >HN Honduras<\/option><option value=\"HK Hong Kong SAR China\" >HK Hong Kong SAR China<\/option><option value=\"HU Hungary\" >HU Hungary<\/option><option value=\"IS Iceland\" >IS Iceland<\/option><option value=\"IN India\" >IN India<\/option><option value=\"ID Indonesia\" >ID Indonesia<\/option><option value=\"IR Iran\" >IR Iran<\/option><option value=\"IQ Iraq\" >IQ Iraq<\/option><option value=\"IE Ireland\" >IE Ireland<\/option><option value=\"IM Isle of Man\" >IM Isle of Man<\/option><option value=\"IL Israel\" >IL Israel<\/option><option value=\"IT Italy\" >IT Italy<\/option><option value=\"JM Jamaica\" >JM Jamaica<\/option><option value=\"JP Japan\" >JP Japan<\/option><option value=\"JE Jersey\" >JE Jersey<\/option><option value=\"JO Jordan\" >JO Jordan<\/option><option value=\"KZ Kazakhstan\" >KZ Kazakhstan<\/option><option value=\"KE Kenya\" >KE Kenya<\/option><option value=\"KI Kiribati\" >KI Kiribati<\/option><option value=\"KW Kuwait\" >KW Kuwait<\/option><option value=\"KG Kyrgyzstan\" >KG Kyrgyzstan<\/option><option value=\"LA Laos\" >LA Laos<\/option><option value=\"LV Latvia\" >LV Latvia<\/option><option value=\"LB Lebanon\" >LB Lebanon<\/option><option value=\"LS Lesotho\" >LS Lesotho<\/option><option value=\"LR Liberia\" >LR Liberia<\/option><option value=\"LY Libya\" >LY Libya<\/option><option value=\"LI Liechtenstein\" >LI Liechtenstein<\/option><option value=\"LT Lithuania\" >LT Lithuania<\/option><option value=\"LU Luxembourg\" >LU Luxembourg<\/option><option value=\"MO Macao SAR China\" >MO Macao SAR China<\/option><option value=\"MG Madagascar\" >MG Madagascar<\/option><option value=\"MW Malawi\" >MW Malawi<\/option><option value=\"MY Malaysia\" >MY Malaysia<\/option><option value=\"MV Maldives\" >MV Maldives<\/option><option value=\"ML Mali\" >ML Mali<\/option><option value=\"MT Malta\" >MT Malta<\/option><option value=\"MH Marshall Islands\" >MH Marshall Islands<\/option><option value=\"MQ Martinique\" >MQ Martinique<\/option><option value=\"MR Mauritania\" >MR Mauritania<\/option><option value=\"MU Mauritius\" >MU Mauritius<\/option><option value=\"YT Mayotte\" >YT Mayotte<\/option><option value=\"MX Mexico\" >MX Mexico<\/option><option value=\"FM Micronesia\" >FM Micronesia<\/option><option value=\"MD Moldova\" >MD Moldova<\/option><option value=\"MC Monaco\" >MC Monaco<\/option><option value=\"MN Mongolia\" >MN Mongolia<\/option><option value=\"ME Montenegro\" >ME Montenegro<\/option><option value=\"MS Montserrat\" >MS Montserrat<\/option><option value=\"MA Morocco\" >MA Morocco<\/option><option value=\"MZ Mozambique\" >MZ Mozambique<\/option><option value=\"MM Myanmar (Burma)\" >MM Myanmar (Burma)<\/option><option value=\"NA Namibia\" >NA Namibia<\/option><option value=\"NR Nauru\" >NR Nauru<\/option><option value=\"NP Nepal\" >NP Nepal<\/option><option value=\"NL Netherlands\" >NL Netherlands<\/option><option value=\"NC New Caledonia\" >NC New Caledonia<\/option><option value=\"NZ New Zealand\" >NZ New Zealand<\/option><option value=\"NI Nicaragua\" >NI Nicaragua<\/option><option value=\"NE Niger\" >NE Niger<\/option><option value=\"NG Nigeria\" >NG Nigeria<\/option><option value=\"NU Niue\" >NU Niue<\/option><option value=\"NF Norfolk Island\" >NF Norfolk Island<\/option><option value=\"KP North Korea\" >KP North Korea<\/option><option value=\"MK North Macedonia\" >MK North Macedonia<\/option><option value=\"MP Northern Mariana Islands\" >MP Northern Mariana Islands<\/option><option value=\"NO Norway\" >NO Norway<\/option><option value=\"OM Oman\" >OM Oman<\/option><option value=\"PK Pakistan\" >PK Pakistan<\/option><option value=\"PW Palau\" >PW Palau<\/option><option value=\"PS Palestinian Territories\" >PS Palestinian Territories<\/option><option value=\"PA Panama\" >PA Panama<\/option><option value=\"PG Papua New Guinea\" >PG Papua New Guinea<\/option><option value=\"PY Paraguay\" >PY Paraguay<\/option><option value=\"PE Peru\" >PE Peru<\/option><option value=\"PH Philippines\" >PH Philippines<\/option><option value=\"PN Pitcairn Islands\" >PN Pitcairn Islands<\/option><option value=\"PL Poland\" >PL Poland<\/option><option value=\"PT Portugal\" >PT Portugal<\/option><option value=\"PR Puerto Rico\" >PR Puerto Rico<\/option><option value=\"QA Qatar\" >QA Qatar<\/option><option value=\"RE R\u00e9union\" >RE R\u00e9union<\/option><option value=\"RO Romania\" >RO Romania<\/option><option value=\"RU Russia\" >RU Russia<\/option><option value=\"RW Rwanda\" >RW Rwanda<\/option><option value=\"WS Samoa\" >WS Samoa<\/option><option value=\"SM San Marino\" >SM San Marino<\/option><option value=\"ST S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe\" >ST S\u00e3o Tom\u00e9 &amp; Pr\u00edncipe<\/option><option value=\"SA Saudi Arabia\" >SA Saudi Arabia<\/option><option value=\"SN Senegal\" >SN Senegal<\/option><option value=\"RS Serbia\" >RS Serbia<\/option><option value=\"SC Seychelles\" >SC Seychelles<\/option><option value=\"SL Sierra Leone\" >SL Sierra Leone<\/option><option value=\"SG Singapore\" >SG Singapore<\/option><option value=\"SX Sint Maarten\" >SX Sint Maarten<\/option><option value=\"SK Slovakia\" >SK Slovakia<\/option><option value=\"SI Slovenia\" >SI Slovenia<\/option><option value=\"SB Solomon Islands\" >SB Solomon Islands<\/option><option value=\"SO Somalia\" >SO Somalia<\/option><option value=\"ZA South Africa\" >ZA South Africa<\/option><option value=\"GS South Georgia &amp; South Sandwich Islands\" >GS South Georgia &amp; South Sandwich Islands<\/option><option value=\"KR South Korea\" >KR South Korea<\/option><option value=\"SS South Sudan\" >SS South Sudan<\/option><option value=\"ES Spain\" >ES Spain<\/option><option value=\"LK Sri Lanka\" >LK Sri Lanka<\/option><option value=\"BL St. Barth\u00e9lemy\" >BL St. Barth\u00e9lemy<\/option><option value=\"SH St. Helena\" >SH St. Helena<\/option><option value=\"KN St. Kitts &amp; Nevis\" >KN St. Kitts &amp; Nevis<\/option><option value=\"LC St. Lucia\" >LC St. Lucia<\/option><option value=\"MF St. Martin\" >MF St. Martin<\/option><option value=\"PM St. Pierre &amp; Miquelon\" >PM St. Pierre &amp; Miquelon<\/option><option value=\"VC St. Vincent &amp; Grenadines\" >VC St. Vincent &amp; Grenadines<\/option><option value=\"SD Sudan\" >SD Sudan<\/option><option value=\"SR Suriname\" >SR Suriname<\/option><option value=\"SJ Svalbard &amp; Jan Mayen\" >SJ Svalbard &amp; Jan Mayen<\/option><option value=\"SE Sweden\" >SE Sweden<\/option><option value=\"CH Switzerland\" >CH Switzerland<\/option><option value=\"SY Syria\" >SY Syria<\/option><option value=\"TW Taiwan\" >TW Taiwan<\/option><option value=\"TJ Tajikistan\" >TJ Tajikistan<\/option><option value=\"TZ Tanzania\" >TZ Tanzania<\/option><option value=\"TH Thailand\" >TH Thailand<\/option><option value=\"TL Timor-Leste\" >TL Timor-Leste<\/option><option value=\"TG Togo\" >TG Togo<\/option><option value=\"TK Tokelau\" >TK Tokelau<\/option><option value=\"TO Tonga\" >TO Tonga<\/option><option value=\"TT Trinidad &amp; Tobago\" >TT Trinidad &amp; Tobago<\/option><option value=\"TN Tunisia\" >TN Tunisia<\/option><option value=\"TR Turkey\" >TR Turkey<\/option><option value=\"TM Turkmenistan\" >TM Turkmenistan<\/option><option value=\"TC Turks &amp; Caicos Islands\" >TC Turks &amp; Caicos Islands<\/option><option value=\"TV Tuvalu\" >TV Tuvalu<\/option><option value=\"UM U.S. Outlying Islands\" >UM U.S. Outlying Islands<\/option><option value=\"VI U.S. Virgin Islands\" >VI U.S. Virgin Islands<\/option><option value=\"UG Uganda\" >UG Uganda<\/option><option value=\"UA Ukraine\" >UA Ukraine<\/option><option value=\"AE United Arab Emirates\" >AE United Arab Emirates<\/option><option value=\"US United States\" >US United States<\/option><option value=\"UY Uruguay\" >UY Uruguay<\/option><option value=\"UZ Uzbekistan\" >UZ Uzbekistan<\/option><option value=\"VU Vanuatu\" >VU Vanuatu<\/option><option value=\"VA Vatican City\" >VA Vatican City<\/option><option value=\"VE Venezuela\" >VE Venezuela<\/option><option value=\"VN Vietnam\" >VN Vietnam<\/option><option value=\"WF Wallis &amp; Futuna\" >WF Wallis &amp; Futuna<\/option><option value=\"EH Western Sahara\" >EH Western Sahara<\/option><option value=\"YE Yemen\" >YE Yemen<\/option><option value=\"ZM Zambia\" >ZM Zambia<\/option><option value=\"ZW Zimbabwe\" >ZW Zimbabwe<\/option><\/select><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div 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