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    {"id":4329,"date":"2023-10-23T13:54:38","date_gmt":"2023-10-23T11:54:38","guid":{"rendered":"https:\/\/insbrok.com\/contrato-adeslas\/"},"modified":"2023-10-23T13:57:10","modified_gmt":"2023-10-23T11:57:10","slug":"contrato-adeslas","status":"publish","type":"page","link":"https:\/\/insbrok.com\/es\/contrato-adeslas\/","title":{"rendered":"Contrato Adeslas"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_51' style='display:none'><div id='gf_51' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_51'  action='\/es\/wp-json\/wp\/v2\/pages\/4329#gf_51' data-formid='51' novalidate><input type=\"hidden\" name=\"gpuid_existing_value_121\" id=\"gpuid_existing_value_121\" value=\"2d7c7a615cb8bb4ba844c0541375eb7c\" \/>\n                        <div class='gform-body gform_body'><div id='gform_page_51_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_51' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_132\" class=\"gfield gfield--type-text gfield--input-type-adminonly_hidden gfield--width-full field_admin_only gf_invisible field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_administrative\"  ><input name='input_132' id='input_51_132' class='gform_hidden' type='hidden' value=''\/><\/div><div id=\"field_51_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DATOS PERSONALES DEL TITULAR DE LA P\u00d3LIZA<\/h3><\/div><fieldset id=\"field_51_62\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_62'>\n                            \n                            <span id='input_51_62_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_62_3' class='gform-field-label gform-field-label--type-sub '>Nombre(s)<\/label>\n                                                    <input type='text' name='input_62.3' id='input_51_62_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_62_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_62_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s) legal(es) completo(s)<\/label>\n                                                            <input type='text' name='input_62.6' id='input_51_62_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_3'>NIF<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_51_3' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_3\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_3'>DNI, NIE o pasaporte<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_51_73' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_2' class='gform_page' data-js='page-field-id-73' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_2' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DATOS DE LA PERSONA A ASEGURAR<\/h3><\/div><fieldset id=\"field_51_63\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_63'>\n                            \n                            <span id='input_51_63_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_63_3' class='gform-field-label gform-field-label--type-sub '>Nombre(s)<\/label>\n                                                    <input type='text' name='input_63.3' id='input_51_63_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_63_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_63_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s) legal(es) completo(s)<\/label>\n                                                            <input type='text' name='input_63.6' id='input_51_63_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_6'>NIF<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_51_6' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_6\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_6'>DNI, NIE o pasaporte<\/div><\/div><div id=\"field_51_90\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_90'>Adjunte el pasaporte o el NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_90' id='input_51_90' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_90 gfield_description_51_90\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_90'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_90'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_90'>Por favor, adjunte un escaneo o una foto de buena calidad del documento<\/div><\/div><div id=\"field_51_71\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_71'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_71' id='input_51_71' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_71_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_71\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_71 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_71_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_71' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_89\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_89'>Edad nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_89' id='input_51_89' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_8'>G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_51_8' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_9'>Peso en kilogramos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_51_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_10'>Altura en cent\u00edmetros<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_51_10' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_11\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_11'>Relaci\u00f3n con el solicitante<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_51_11' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_75' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_75' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_3' class='gform_page' data-js='page-field-id-75' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_3' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_76\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n de contacto<\/h3><\/div><div id=\"field_51_77\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_77'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_77' id='input_51_77' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_78\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_78'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_78' id='input_51_78' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_51_74\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_51_74' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_51_74_1_container' >\n                                        <label for='input_51_74_1' id='input_51_74_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                        <input type='text' name='input_74.1' id='input_51_74_1' value=''    aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_51_74_3_container' >\n                                    <label for='input_51_74_3' id='input_51_74_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                    <input type='text' name='input_74.3' id='input_51_74_3' value=''    aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_51_74_4_container' >\n                                        <label for='input_51_74_4' id='input_51_74_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                        <input type='text' name='input_74.4' id='input_51_74_4' value=''      aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_51_74_5_container' >\n                                    <label for='input_51_74_5' id='input_51_74_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                    <input type='text' name='input_74.5' id='input_51_74_5' value=''    aria-required='true'    \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_51_74_6_container' >\n                                        <label for='input_51_74_6' id='input_51_74_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                        <select name='input_74.6' id='input_51_74_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option> <\/select>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_72' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_72' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_4' class='gform_page' data-js='page-field-id-72' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_4' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DATOS DEL REPRESENTANTE LEGAL<\/h3><\/div><fieldset id=\"field_51_64\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_64'>\n                            \n                            <span id='input_51_64_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_64_3' class='gform-field-label gform-field-label--type-sub '>Nombre(s)<\/label>\n                                                    <input type='text' name='input_64.3' id='input_51_64_3' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_64_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_64_6' class='gform-field-label gform-field-label--type-sub '>Apellido(s) legal(es) completo(s)<\/label>\n                                                            <input type='text' name='input_64.6' id='input_51_64_6' value=''   aria-required='false'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_17\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_17'>NIF<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_51_17' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_17\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_17'>DNI, NIE o pasaporte<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_65' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_5' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_5' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_80\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_80'>P\u00f3liza Fecha de entrada en vigor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_51_80'>Por favor, seleccione el primer d\u00eda del mes como fecha de inicio de su p\u00f3liza. Las p\u00f3lizas \u00fanicamente pueden comenzar el primer d\u00eda de cada mes.<\/div><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_80' id='input_51_80' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_80_date_format gfield_description_51_80\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_80\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_80 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_80_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_80' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_79' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_79' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_6' class='gform_page' data-js='page-field-id-79' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_6' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_18\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">INFORMACI\u00d3N SANITARIA<\/h3><\/div><fieldset id=\"field_51_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. \u00bfSufre o ha sufrido alguna enfermedad en los \u00faltimos cinco a\u00f1os?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_49'>\n\t\t\t<div class='gchoice gchoice_51_49_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='yes'  id='choice_51_49_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_49_0' id='label_51_49_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_49_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_49' type='radio' value='no'  id='choice_51_49_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_49_1' id='label_51_49_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_20'>Especifique cu\u00e1l, fecha, tratamiento y evoluci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_51_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_50\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfLas enfermedades que ha padecido hasta ahora le han dejado alguna lesi\u00f3n o secuela?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_50'>\n\t\t\t<div class='gchoice gchoice_51_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='yes'  id='choice_51_50_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_50_0' id='label_51_50_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='no'  id='choice_51_50_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_50_1' id='label_51_50_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_22'>Especifique<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_51_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. \u00bfHa sido operado o ingresado en el hospital en alg\u00fan momento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_51'>\n\t\t\t<div class='gchoice gchoice_51_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='yes'  id='choice_51_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_51_0' id='label_51_51_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='no'  id='choice_51_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_51_1' id='label_51_51_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_24'>Especifique la fecha y el motivo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_51_24' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_25\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_25'>3. \u00bfEn qu\u00e9 fecha y por qu\u00e9 motivo visit\u00f3 al m\u00e9dico la \u00faltima vez?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_25' id='input_51_25' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_25_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_25_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_25' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_26'>Raz\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_51_26' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_61'>Especifique la especialidad y la pr\u00f3xima fecha de visita<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_51_61' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. \u00bfHa padecido o padece alg\u00fan defecto f\u00edsico, deformidad, discapacidad o lesi\u00f3n cong\u00e9nita?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_52'>\n\t\t\t<div class='gchoice gchoice_51_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='yes'  id='choice_51_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_52_0' id='label_51_52_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='no'  id='choice_51_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_52_1' id='label_51_52_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_29'>Especifique cu\u00e1l, fecha, tratamiento y evoluci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_51_29' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_53\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. \u00bfHa sufrido alg\u00fan traumatismo o accidente?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_53'>\n\t\t\t<div class='gchoice gchoice_51_53_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='yes'  id='choice_51_53_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_53_0' id='label_51_53_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_53_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_53' type='radio' value='no'  id='choice_51_53_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_53_1' id='label_51_53_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_31'>Especifique fecha, tratamiento y secuelas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_51_31' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. \u00bfEst\u00e1 actualmente bajo control m\u00e9dico o sigue alg\u00fan tipo de tratamiento?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_54'>\n\t\t\t<div class='gchoice gchoice_51_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='yes'  id='choice_51_54_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_54_0' id='label_51_54_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='no'  id='choice_51_54_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_54_1' id='label_51_54_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_33'>Especifique cu\u00e1l<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_51_33' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) \u00bfSabe si necesitar\u00e1 alg\u00fan estudio o tratamiento en el pr\u00f3ximo a\u00f1o?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_55'>\n\t\t\t<div class='gchoice gchoice_51_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='yes'  id='choice_51_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_0' id='label_51_55_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='no'  id='choice_51_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_1' id='label_51_55_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_35'>Especifique cu\u00e1l<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_51_35' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) \u00bfNecesitar\u00e1 ser hospitalizado en ese periodo de tiempo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_56'>\n\t\t\t<div class='gchoice gchoice_51_56_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='yes'  id='choice_51_56_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_56_0' id='label_51_56_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_56_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_56' type='radio' value='no'  id='choice_51_56_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_56_1' id='label_51_56_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_37'>Indique el motivo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_51_37' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. \u00bfEs o ha sido fumador?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_57'>\n\t\t\t<div class='gchoice gchoice_51_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='yes'  id='choice_51_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_57_0' id='label_51_57_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='no'  id='choice_51_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_57_1' id='label_51_57_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_39'>Especifique la cantidad por d\u00eda<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_51_39' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfConsume o ha consumido bebidas alcoh\u00f3licas con regularidad?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_58'>\n\t\t\t<div class='gchoice gchoice_51_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='yes'  id='choice_51_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_58_0' id='label_51_58_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='no'  id='choice_51_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_58_1' id='label_51_58_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_41'>Especifique la cantidad diaria y el tipo de bebidas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_51_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_59\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfConsume o ha consumido estupefacientes?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_59'>\n\t\t\t<div class='gchoice gchoice_51_59_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='yes'  id='choice_51_59_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_59_0' id='label_51_59_0' class='gform-field-label gform-field-label--type-inline'>S\u00cd<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_59_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_59' type='radio' value='no'  id='choice_51_59_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_59_1' id='label_51_59_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_42\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_42'>Especifique el tipo de productos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_51_42' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_98\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_invisible field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_98'>Number of Beneficiaries<\/label><div class='ginput_container ginput_container_number'><input name='input_98' id='input_51_98' type='number' step='any' min='1' max='7' value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_51_98\" \/><div class='gfield_description instruction ' id='gfield_instruction_51_98'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>7<\/strong>.<\/div><\/div><\/div><div id=\"field_51_99\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_invisible field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_99'>este Beneficiario nr<\/label><div class='ginput_container ginput_container_number'><input name='input_99' id='input_51_99' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_122\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gf_invisible gfield_calculation field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_122'>Benific. diferencia<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_51_122' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\" aria-describedby=\"gfield_description_51_122\" \/><\/div><div class='gfield_description' id='gfield_description_51_122'>si \"0\" enviar supp notif+ crear adhesi\u00f3n + enviar a pago<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_135' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_135' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_7' class='gform_page' data-js='page-field-id-135' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_7' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_136\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 2 DETAILS<\/h3><\/div><fieldset id=\"field_51_137\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_137'>\n                            \n                            <span id='input_51_137_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_137_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_137.3' id='input_51_137_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_137_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_137_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_137.6' id='input_51_137_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_138\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_138'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_51_138' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_138\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_138'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_139\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_139'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_139' id='input_51_139' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_139 gfield_description_51_139\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_139'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_139'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_139'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_140\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_140'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_140' id='input_51_140' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_140_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_140\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_140 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_140_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_140' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_141\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_141'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_141' id='input_51_141' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_144'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_51_144' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_143\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_143'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_51_143' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_142'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_51_142' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_145\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_145'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_145' id='input_51_145' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_146\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_147\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_147'>\n\t\t\t<div class='gchoice gchoice_51_147_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='yes'  id='choice_51_147_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_147_0' id='label_51_147_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_147_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_147' type='radio' value='no'  id='choice_51_147_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_147_1' id='label_51_147_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_148\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_148'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_51_148' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_149'>\n\t\t\t<div class='gchoice gchoice_51_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='yes'  id='choice_51_149_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_149_0' id='label_51_149_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='no'  id='choice_51_149_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_149_1' id='label_51_149_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_150'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_51_150' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_151\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_151'>\n\t\t\t<div class='gchoice gchoice_51_151_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='yes'  id='choice_51_151_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_151_0' id='label_51_151_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_151_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_151' type='radio' value='no'  id='choice_51_151_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_151_1' id='label_51_151_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_152\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_152'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_51_152' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_153\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_153'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_153' id='input_51_153' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_153_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_153_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_153' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_154\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_154'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_51_154' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_155'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_51_155' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_156\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_156'>\n\t\t\t<div class='gchoice gchoice_51_156_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='yes'  id='choice_51_156_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_156_0' id='label_51_156_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_156_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_156' type='radio' value='no'  id='choice_51_156_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_156_1' id='label_51_156_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_157\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_157'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_157' id='input_51_157' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_158'>\n\t\t\t<div class='gchoice gchoice_51_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='yes'  id='choice_51_158_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_158_0' id='label_51_158_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='no'  id='choice_51_158_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_158_1' id='label_51_158_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_159\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_159'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_159' id='input_51_159' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_160\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_160'>\n\t\t\t<div class='gchoice gchoice_51_160_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='yes'  id='choice_51_160_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_160_0' id='label_51_160_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_160_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_160' type='radio' value='no'  id='choice_51_160_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_160_1' id='label_51_160_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_161\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_161'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_161' id='input_51_161' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_162\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_162'>\n\t\t\t<div class='gchoice gchoice_51_162_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='yes'  id='choice_51_162_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_162_0' id='label_51_162_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_162_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_162' type='radio' value='no'  id='choice_51_162_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_162_1' id='label_51_162_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_163\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_163'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_163' id='input_51_163' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_164\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_164'>\n\t\t\t<div class='gchoice gchoice_51_164_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='yes'  id='choice_51_164_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_164_0' id='label_51_164_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_164_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_164' type='radio' value='no'  id='choice_51_164_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_164_1' id='label_51_164_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_165\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_165'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_165' id='input_51_165' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_166\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_166'>\n\t\t\t<div class='gchoice gchoice_51_166_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='yes'  id='choice_51_166_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_166_0' id='label_51_166_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_166_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_166' type='radio' value='no'  id='choice_51_166_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_166_1' id='label_51_166_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_167\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_167'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_167' id='input_51_167' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_168\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_168'>\n\t\t\t<div class='gchoice gchoice_51_168_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='yes'  id='choice_51_168_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_168_0' id='label_51_168_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_168_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_168' type='radio' value='no'  id='choice_51_168_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_168_1' id='label_51_168_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_169\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_169'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_51_169' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_170'>\n\t\t\t<div class='gchoice gchoice_51_170_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='yes'  id='choice_51_170_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_170_0' id='label_51_170_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_170_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_170' type='radio' value='no'  id='choice_51_170_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_170_1' id='label_51_170_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_171\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_171'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_171' id='input_51_171' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_172' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_172' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_8' class='gform_page' data-js='page-field-id-172' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_8' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_173\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 3 DETAILS<\/h3><\/div><fieldset id=\"field_51_174\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_174'>\n                            \n                            <span id='input_51_174_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_174_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_174.3' id='input_51_174_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_174_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_174_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_174.6' id='input_51_174_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_175\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_175'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_175' id='input_51_175' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_175\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_175'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_176\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_176'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_176' id='input_51_176' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_176 gfield_description_51_176\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_176'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_176'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_176'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_177\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_177'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_177' id='input_51_177' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_177_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_177\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_177 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_177_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_177' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_178\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_178'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_178' id='input_51_178' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_179\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_179'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_179' id='input_51_179' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_180\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_180'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_51_180' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_181\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_181'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_181' id='input_51_181' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_182\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_182'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_51_182' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_183\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_184\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_184'>\n\t\t\t<div class='gchoice gchoice_51_184_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='yes'  id='choice_51_184_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_184_0' id='label_51_184_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_184_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_184' type='radio' value='no'  id='choice_51_184_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_184_1' id='label_51_184_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_185\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_185'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_185' id='input_51_185' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_186\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_186'>\n\t\t\t<div class='gchoice gchoice_51_186_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='yes'  id='choice_51_186_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_186_0' id='label_51_186_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_186_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_186' type='radio' value='no'  id='choice_51_186_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_186_1' id='label_51_186_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_187\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_187'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_187' id='input_51_187' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_188\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_188'>\n\t\t\t<div class='gchoice gchoice_51_188_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='yes'  id='choice_51_188_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_188_0' id='label_51_188_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_188_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_188' type='radio' value='no'  id='choice_51_188_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_188_1' id='label_51_188_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_189\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_189'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_189' id='input_51_189' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_190\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_190'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_190' id='input_51_190' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_190_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_190_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_190' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_191\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_191'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_191' id='input_51_191' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_192\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_192'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_51_192' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_193\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_193'>\n\t\t\t<div class='gchoice gchoice_51_193_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='yes'  id='choice_51_193_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_193_0' id='label_51_193_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_193_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_193' type='radio' value='no'  id='choice_51_193_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_193_1' id='label_51_193_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_194\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_194'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_194' id='input_51_194' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_195\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_195'>\n\t\t\t<div class='gchoice gchoice_51_195_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='yes'  id='choice_51_195_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_195_0' id='label_51_195_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_195_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_195' type='radio' value='no'  id='choice_51_195_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_195_1' id='label_51_195_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_196\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_196'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_196' id='input_51_196' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_197\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_197'>\n\t\t\t<div class='gchoice gchoice_51_197_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='yes'  id='choice_51_197_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_197_0' id='label_51_197_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_197_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_197' type='radio' value='no'  id='choice_51_197_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_197_1' id='label_51_197_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_198\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_198'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_198' id='input_51_198' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_199\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_199'>\n\t\t\t<div class='gchoice gchoice_51_199_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='yes'  id='choice_51_199_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_199_0' id='label_51_199_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_199_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_199' type='radio' value='no'  id='choice_51_199_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_199_1' id='label_51_199_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_200\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_200'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_200' id='input_51_200' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_201\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_201'>\n\t\t\t<div class='gchoice gchoice_51_201_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_201' type='radio' value='yes'  id='choice_51_201_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_201_0' id='label_51_201_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_201_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_201' type='radio' value='no'  id='choice_51_201_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_201_1' id='label_51_201_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_202\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_202'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_202' id='input_51_202' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_203\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_203'>\n\t\t\t<div class='gchoice gchoice_51_203_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='yes'  id='choice_51_203_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_203_0' id='label_51_203_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_203_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_203' type='radio' value='no'  id='choice_51_203_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_203_1' id='label_51_203_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_204\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_204'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_51_204' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_205\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_205'>\n\t\t\t<div class='gchoice gchoice_51_205_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='yes'  id='choice_51_205_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_205_0' id='label_51_205_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_205_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_205' type='radio' value='no'  id='choice_51_205_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_205_1' id='label_51_205_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_206\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_206'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_51_206' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_207\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_207'>\n\t\t\t<div class='gchoice gchoice_51_207_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='yes'  id='choice_51_207_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_207_0' id='label_51_207_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_207_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_207' type='radio' value='no'  id='choice_51_207_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_207_1' id='label_51_207_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_208\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_208'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_208' id='input_51_208' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_209' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_209' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_9' class='gform_page' data-js='page-field-id-209' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_9' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_210\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 4 DETAILS<\/h3><\/div><fieldset id=\"field_51_211\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_211'>\n                            \n                            <span id='input_51_211_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_211_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_211.3' id='input_51_211_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_211_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_211_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_211.6' id='input_51_211_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_212\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_212'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_212' id='input_51_212' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_212\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_212'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_213\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_213'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_213' id='input_51_213' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_213 gfield_description_51_213\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_213'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_213'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_213'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_214\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_214'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_214' id='input_51_214' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_214_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_214\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_214 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_214_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_214' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_215\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_215'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_215' id='input_51_215' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_216\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_216'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_216' id='input_51_216' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_217\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_217'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_217' id='input_51_217' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_218\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_218'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_218' id='input_51_218' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_219\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_219'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_219' id='input_51_219' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_220\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_221\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_221'>\n\t\t\t<div class='gchoice gchoice_51_221_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='yes'  id='choice_51_221_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_221_0' id='label_51_221_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_221_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_221' type='radio' value='no'  id='choice_51_221_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_221_1' id='label_51_221_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_222\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_222'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_51_222' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_223\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_223'>\n\t\t\t<div class='gchoice gchoice_51_223_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_223' type='radio' value='yes'  id='choice_51_223_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_223_0' id='label_51_223_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_223_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_223' type='radio' value='no'  id='choice_51_223_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_223_1' id='label_51_223_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_224\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_224'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_224' id='input_51_224' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_225\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_225'>\n\t\t\t<div class='gchoice gchoice_51_225_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='yes'  id='choice_51_225_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_225_0' id='label_51_225_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_225_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_225' type='radio' value='no'  id='choice_51_225_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_225_1' id='label_51_225_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_226\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_226'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_226' id='input_51_226' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_227\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_227'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_227' id='input_51_227' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_227_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_227_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_227' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_228\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_228'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_228' id='input_51_228' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_229\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_229'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_229' id='input_51_229' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_230\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_230'>\n\t\t\t<div class='gchoice gchoice_51_230_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='yes'  id='choice_51_230_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_230_0' id='label_51_230_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_230_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_230' type='radio' value='no'  id='choice_51_230_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_230_1' id='label_51_230_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_231\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_231'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_51_231' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_232\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_232'>\n\t\t\t<div class='gchoice gchoice_51_232_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='yes'  id='choice_51_232_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_232_0' id='label_51_232_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_232_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_232' type='radio' value='no'  id='choice_51_232_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_232_1' id='label_51_232_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_233\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_233'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_51_233' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_234\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_234'>\n\t\t\t<div class='gchoice gchoice_51_234_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='yes'  id='choice_51_234_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_234_0' id='label_51_234_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_234_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_234' type='radio' value='no'  id='choice_51_234_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_234_1' id='label_51_234_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_235\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_235'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_235' id='input_51_235' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_236\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_236'>\n\t\t\t<div class='gchoice gchoice_51_236_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='yes'  id='choice_51_236_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_236_0' id='label_51_236_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_236_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_236' type='radio' value='no'  id='choice_51_236_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_236_1' id='label_51_236_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_237\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_237'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_237' id='input_51_237' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_238\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_238'>\n\t\t\t<div class='gchoice gchoice_51_238_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='yes'  id='choice_51_238_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_238_0' id='label_51_238_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_238_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_238' type='radio' value='no'  id='choice_51_238_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_238_1' id='label_51_238_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_239\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_239'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_239' id='input_51_239' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_240\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_240'>\n\t\t\t<div class='gchoice gchoice_51_240_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='yes'  id='choice_51_240_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_240_0' id='label_51_240_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_240_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_240' type='radio' value='no'  id='choice_51_240_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_240_1' id='label_51_240_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_241\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_241'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_241' id='input_51_241' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_242\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_242'>\n\t\t\t<div class='gchoice gchoice_51_242_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='yes'  id='choice_51_242_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_242_0' id='label_51_242_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_242_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_242' type='radio' value='no'  id='choice_51_242_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_242_1' id='label_51_242_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_243\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_243'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_243' id='input_51_243' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_244'>\n\t\t\t<div class='gchoice gchoice_51_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='yes'  id='choice_51_244_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_244_0' id='label_51_244_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='no'  id='choice_51_244_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_244_1' id='label_51_244_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_245\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_245'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_245' id='input_51_245' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_246' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_246' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_10' class='gform_page' data-js='page-field-id-246' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_10' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_247\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 5 DETAILS<\/h3><\/div><fieldset id=\"field_51_248\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_248'>\n                            \n                            <span id='input_51_248_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_248_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_248.3' id='input_51_248_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_248_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_248_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_248.6' id='input_51_248_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_249\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_249'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_249' id='input_51_249' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_249\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_249'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_250\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_250'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_250' id='input_51_250' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_250 gfield_description_51_250\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_250'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_250'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_250'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_251\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_251'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_251' id='input_51_251' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_251_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_251\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_251 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_251_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_251' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_252\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_252'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_252' id='input_51_252' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_253\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_253'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_253' id='input_51_253' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_254\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_254'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_254' id='input_51_254' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_255\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_255'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_51_255' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_256\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_256'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_256' id='input_51_256' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_257\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_258\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_258'>\n\t\t\t<div class='gchoice gchoice_51_258_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='yes'  id='choice_51_258_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_258_0' id='label_51_258_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_258_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_258' type='radio' value='no'  id='choice_51_258_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_258_1' id='label_51_258_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_259\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_259'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_259' id='input_51_259' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_260\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_260'>\n\t\t\t<div class='gchoice gchoice_51_260_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_260' type='radio' value='yes'  id='choice_51_260_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_260_0' id='label_51_260_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_260_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_260' type='radio' value='no'  id='choice_51_260_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_260_1' id='label_51_260_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_261\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_261'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_261' id='input_51_261' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_262\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_262'>\n\t\t\t<div class='gchoice gchoice_51_262_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_262' type='radio' value='yes'  id='choice_51_262_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_262_0' id='label_51_262_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_262_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_262' type='radio' value='no'  id='choice_51_262_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_262_1' id='label_51_262_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_263\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_263'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_263' id='input_51_263' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_264\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_264'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_264' id='input_51_264' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_264_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_264_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_264' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_265\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_265'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_265' id='input_51_265' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_266\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_266'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_266' id='input_51_266' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_267\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_267'>\n\t\t\t<div class='gchoice gchoice_51_267_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='yes'  id='choice_51_267_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_267_0' id='label_51_267_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_267_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_267' type='radio' value='no'  id='choice_51_267_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_267_1' id='label_51_267_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_268\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_268'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_268' id='input_51_268' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_269\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_269'>\n\t\t\t<div class='gchoice gchoice_51_269_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_269' type='radio' value='yes'  id='choice_51_269_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_269_0' id='label_51_269_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_269_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_269' type='radio' value='no'  id='choice_51_269_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_269_1' id='label_51_269_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_270\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_270'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_270' id='input_51_270' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_271\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_271'>\n\t\t\t<div class='gchoice gchoice_51_271_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_271' type='radio' value='yes'  id='choice_51_271_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_271_0' id='label_51_271_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_271_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_271' type='radio' value='no'  id='choice_51_271_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_271_1' id='label_51_271_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_272\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_272'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_272' id='input_51_272' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_273\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_273'>\n\t\t\t<div class='gchoice gchoice_51_273_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_273' type='radio' value='yes'  id='choice_51_273_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_273_0' id='label_51_273_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_273_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_273' type='radio' value='no'  id='choice_51_273_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_273_1' id='label_51_273_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_274\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_274'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_274' id='input_51_274' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_275\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_275'>\n\t\t\t<div class='gchoice gchoice_51_275_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_275' type='radio' value='yes'  id='choice_51_275_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_275_0' id='label_51_275_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_275_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_275' type='radio' value='no'  id='choice_51_275_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_275_1' id='label_51_275_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_276\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_276'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_276' id='input_51_276' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_277\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_277'>\n\t\t\t<div class='gchoice gchoice_51_277_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='yes'  id='choice_51_277_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_0' id='label_51_277_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='no'  id='choice_51_277_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_1' id='label_51_277_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_278\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_278'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_278' id='input_51_278' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_279\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_279'>\n\t\t\t<div class='gchoice gchoice_51_279_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='yes'  id='choice_51_279_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_279_0' id='label_51_279_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_279_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_279' type='radio' value='no'  id='choice_51_279_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_279_1' id='label_51_279_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_280\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_280'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_280' id='input_51_280' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_281\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_281'>\n\t\t\t<div class='gchoice gchoice_51_281_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='yes'  id='choice_51_281_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_281_0' id='label_51_281_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_281_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_281' type='radio' value='no'  id='choice_51_281_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_281_1' id='label_51_281_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_282\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_282'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_282' id='input_51_282' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_283' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_51_283' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_11' class='gform_page' data-js='page-field-id-283' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_11' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_284\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 6 DETAILS<\/h3><\/div><fieldset id=\"field_51_285\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_285'>\n                            \n                            <span id='input_51_285_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_285_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_285.3' id='input_51_285_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_285_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_285_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_285.6' id='input_51_285_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_286\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_286'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_286' id='input_51_286' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_286\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_286'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_287\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_287'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_287' id='input_51_287' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_287 gfield_description_51_287\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_287'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_287'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_287'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_288\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_288'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_288' id='input_51_288' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_288_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_288\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_288 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_288_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_288' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_289\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_289'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_289' id='input_51_289' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_290\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_290'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_290' id='input_51_290' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_291\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_291'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_291' id='input_51_291' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_292\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_292'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_51_292' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_293\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_293'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_293' id='input_51_293' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_294\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_295\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_295'>\n\t\t\t<div class='gchoice gchoice_51_295_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_295' type='radio' value='yes'  id='choice_51_295_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_295_0' id='label_51_295_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_295_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_295' type='radio' value='no'  id='choice_51_295_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_295_1' id='label_51_295_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_296\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_296'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_296' id='input_51_296' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_297\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_297'>\n\t\t\t<div class='gchoice gchoice_51_297_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_297' type='radio' value='yes'  id='choice_51_297_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_297_0' id='label_51_297_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_297_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_297' type='radio' value='no'  id='choice_51_297_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_297_1' id='label_51_297_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_298\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_298'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_298' id='input_51_298' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_299\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_299'>\n\t\t\t<div class='gchoice gchoice_51_299_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='yes'  id='choice_51_299_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_299_0' id='label_51_299_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_299_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_299' type='radio' value='no'  id='choice_51_299_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_299_1' id='label_51_299_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_300\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_300'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_300' id='input_51_300' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_301\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_301'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_301' id='input_51_301' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_301_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_301_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_301' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_302\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_302'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_302' id='input_51_302' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_303\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_303'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_51_303' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_304\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_304'>\n\t\t\t<div class='gchoice gchoice_51_304_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='yes'  id='choice_51_304_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_304_0' id='label_51_304_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_304_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_304' type='radio' value='no'  id='choice_51_304_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_304_1' id='label_51_304_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_305\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_305'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_305' id='input_51_305' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_306\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_306'>\n\t\t\t<div class='gchoice gchoice_51_306_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_306' type='radio' value='yes'  id='choice_51_306_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_306_0' id='label_51_306_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_306_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_306' type='radio' value='no'  id='choice_51_306_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_306_1' id='label_51_306_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_307\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_307'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_307' id='input_51_307' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_308\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_308'>\n\t\t\t<div class='gchoice gchoice_51_308_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_308' type='radio' value='yes'  id='choice_51_308_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_308_0' id='label_51_308_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_308_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_308' type='radio' value='no'  id='choice_51_308_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_308_1' id='label_51_308_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_309\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_309'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_309' id='input_51_309' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_310\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_310'>\n\t\t\t<div class='gchoice gchoice_51_310_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_310' type='radio' value='yes'  id='choice_51_310_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_310_0' id='label_51_310_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_310_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_310' type='radio' value='no'  id='choice_51_310_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_310_1' id='label_51_310_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_311\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_311'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_311' id='input_51_311' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_312\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_312'>\n\t\t\t<div class='gchoice gchoice_51_312_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='yes'  id='choice_51_312_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_312_0' id='label_51_312_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_312_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_312' type='radio' value='no'  id='choice_51_312_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_312_1' id='label_51_312_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_313\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_313'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_313' id='input_51_313' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_314\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_314'>\n\t\t\t<div class='gchoice gchoice_51_314_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='yes'  id='choice_51_314_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_314_0' id='label_51_314_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_314_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_314' type='radio' value='no'  id='choice_51_314_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_314_1' id='label_51_314_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_315\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_315'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_315' id='input_51_315' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_316\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_316'>\n\t\t\t<div class='gchoice gchoice_51_316_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_316' type='radio' value='yes'  id='choice_51_316_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_316_0' id='label_51_316_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_316_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_316' type='radio' value='no'  id='choice_51_316_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_316_1' id='label_51_316_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_317\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_317'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_317' id='input_51_317' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_318\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_318'>\n\t\t\t<div class='gchoice gchoice_51_318_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='yes'  id='choice_51_318_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_318_0' id='label_51_318_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_318_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_318' type='radio' value='no'  id='choice_51_318_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_318_1' id='label_51_318_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_319\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_319'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_319' id='input_51_319' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_320' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_51_320' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_12' class='gform_page' data-js='page-field-id-320' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_12' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_321\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">PERSON 7 DETAILS<\/h3><\/div><fieldset id=\"field_51_322\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_322'>\n                            \n                            <span id='input_51_322_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_51_322_3' class='gform-field-label gform-field-label--type-sub '>Full legal first and middle names<\/label>\n                                                    <input type='text' name='input_322.3' id='input_51_322_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_51_322_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_51_322_6' class='gform-field-label gform-field-label--type-sub '>Full legal last name(s)<\/label>\n                                                            <input type='text' name='input_322.6' id='input_51_322_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_323\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_323'>Tax ID No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_323' id='input_51_323' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_323\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_323'>DNI, NIE, or Passport<\/div><\/div><div id=\"field_51_324\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_324'>Please attach the passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_324' id='input_51_324' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_324 gfield_description_51_324\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_324'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_324'><\/div> <\/div><div class='gfield_description' id='gfield_description_51_324'>Please attach a scan or good quality photo of the document<\/div><\/div><div id=\"field_51_325\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_325'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_325' id='input_51_325' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy_dash has-inline-datepicker_no_icon ghas-inline-datepicker-no-icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_51_325_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_51_325\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy_dash\"><\/div><style type=\"text\/css\">#datepicker_51_325 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_51_325_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_325' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_326\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_invisible gfield_contains_required gfield_calculation field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_326'>Age nr<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_326' id='input_51_326' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_327\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_327'>Height in centimeters<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_327' id='input_51_327' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_328\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_328'>Weight in kilograms<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_328' id='input_51_328' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_329\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_329'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_329' id='input_51_329' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_330\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_330'>Relationship with the applicant<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_330' id='input_51_330' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_331\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">HEALTH-RELATED INFORMATION<\/h3><\/div><fieldset id=\"field_51_332\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >1. Do you suffer or have you suffered any illness in the last five years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_332'>\n\t\t\t<div class='gchoice gchoice_51_332_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_332' type='radio' value='yes'  id='choice_51_332_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_332_0' id='label_51_332_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_332_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_332' type='radio' value='no'  id='choice_51_332_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_332_1' id='label_51_332_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_333\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_333'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_333' id='input_51_333' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_334\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have the illnesses you have suffered until now left any lesions or sequelae?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_334'>\n\t\t\t<div class='gchoice gchoice_51_334_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_334' type='radio' value='yes'  id='choice_51_334_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_334_0' id='label_51_334_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_334_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_334' type='radio' value='no'  id='choice_51_334_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_334_1' id='label_51_334_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_335\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_335'>Please specify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_335' id='input_51_335' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_336\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >2. Have you been operated on or admitted into hospital at any time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_336'>\n\t\t\t<div class='gchoice gchoice_51_336_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_336' type='radio' value='yes'  id='choice_51_336_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_336_0' id='label_51_336_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_336_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_336' type='radio' value='no'  id='choice_51_336_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_336_1' id='label_51_336_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_337\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_337'>Please specify date and reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_337' id='input_51_337' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_338\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_338'>3. At what date and for what reason did you visit the doctor the last time?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_338' id='input_51_338' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_51_338_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_338_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_338' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_339\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_339'>Reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_339' id='input_51_339' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_340\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_340'>Please specify speciality and next date for visit<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_340' id='input_51_340' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_341\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >4. Have you suffered or do you suffer any physical defect, deformity, disability or congenital lesion?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_341'>\n\t\t\t<div class='gchoice gchoice_51_341_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_341' type='radio' value='yes'  id='choice_51_341_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_341_0' id='label_51_341_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_341_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_341' type='radio' value='no'  id='choice_51_341_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_341_1' id='label_51_341_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_342\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_342'>Please specify which, date, treatment and evolution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_342' id='input_51_342' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_343\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >5. Have you suffered any o traumatism or accident?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_343'>\n\t\t\t<div class='gchoice gchoice_51_343_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_343' type='radio' value='yes'  id='choice_51_343_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_343_0' id='label_51_343_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_343_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_343' type='radio' value='no'  id='choice_51_343_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_343_1' id='label_51_343_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_344\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_344'>Please specify date, treatment and sequelae<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_344' id='input_51_344' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_345\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >6. Are you currently under medical control or following any kind of treatment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_345'>\n\t\t\t<div class='gchoice gchoice_51_345_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_345' type='radio' value='yes'  id='choice_51_345_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_345_0' id='label_51_345_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_345_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_345' type='radio' value='no'  id='choice_51_345_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_345_1' id='label_51_345_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_346\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_346'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_346' id='input_51_346' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_347\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >a) Do you know whether you will need any study or treatment within the next year?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_347'>\n\t\t\t<div class='gchoice gchoice_51_347_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_347' type='radio' value='yes'  id='choice_51_347_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_347_0' id='label_51_347_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_347_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_347' type='radio' value='no'  id='choice_51_347_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_347_1' id='label_51_347_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_348\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_348'>Please specify which<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_348' id='input_51_348' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_349\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >b) Will you need to be admitted into hospital within that time period?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_349'>\n\t\t\t<div class='gchoice gchoice_51_349_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_349' type='radio' value='yes'  id='choice_51_349_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_349_0' id='label_51_349_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_349_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_349' type='radio' value='no'  id='choice_51_349_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_349_1' id='label_51_349_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_350\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_350'>Please state the reason<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_350' id='input_51_350' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_351\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >7. Are you or have you been a smoker?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_351'>\n\t\t\t<div class='gchoice gchoice_51_351_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_351' type='radio' value='yes'  id='choice_51_351_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_351_0' id='label_51_351_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_351_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_351' type='radio' value='no'  id='choice_51_351_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_351_1' id='label_51_351_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_352\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_352'>Please specify amount per day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_352' id='input_51_352' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_353\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed alcoholic drinks regularly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_353'>\n\t\t\t<div class='gchoice gchoice_51_353_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_353' type='radio' value='yes'  id='choice_51_353_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_353_0' id='label_51_353_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_353_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_353' type='radio' value='no'  id='choice_51_353_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_353_1' id='label_51_353_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_354\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_354'>Please specify amount per day and type of drinks<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_354' id='input_51_354' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_355\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you consume or have you consumed narcotics?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_355'>\n\t\t\t<div class='gchoice gchoice_51_355_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_355' type='radio' value='yes'  id='choice_51_355_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_355_0' id='label_51_355_0' class='gform-field-label gform-field-label--type-inline'>YES<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_355_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_355' type='radio' value='no'  id='choice_51_355_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_355_1' id='label_51_355_1' class='gform-field-label gform-field-label--type-inline'>NO<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_356\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_356'>Please specify the type of products<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_356' id='input_51_356' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_85' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_51_85' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_13' class='gform_page' data-js='page-field-id-85' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_13' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_88\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-five-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_88'>Importe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_88' id='input_51_88' type='text' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div data-fieldId=\"88\" class=\"spacer gfield\" style=\"grid-column: span 7;\" data-groupId=\"462ebfa0\"><\/div><div id=\"field_51_87\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_87'>Periodo de cobertura en meses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_87' id='input_51_87' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div data-fieldId=\"87\" class=\"spacer gfield\" style=\"grid-column: span 7;\" data-groupId=\"94b423b2\"><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_95' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_51_95' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_14' class='gform_page' data-js='page-field-id-95' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_14' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_96\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_51_96'>Precio mensual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_96' id='input_51_96' type='text' step='any'   value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_124\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Precio total para todos los solicitantes<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_51_86' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_51_86' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_15' class='gform_page' data-js='page-field-id-86' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_15' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_51_44\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >El abajo firmante manifiesta, bajo su responsabilidad, que sus respuestas a las preguntas formuladas son veraces y completas, autorizando a SegurCaixa Adeslas a realizar cuantas comprobaciones estime convenientes sobre el origen y evoluci\u00f3n de las enfermedades o dolencias que puedan, dado el caso, requerir la asistencia prevista en esta P\u00f3liza. El abajo firmante autoriza a la Compa\u00f1\u00eda, en caso de enfermedad, a ponerse en contacto con los m\u00e9dicos intervinientes.<\/div><div id=\"field_51_45\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >SegurCaixa Adeslas podr\u00e1 resolver sobre la P\u00f3liza en el plazo de un mes desde que tenga conocimiento de las reservas o inexactitudes del declarante en la cumplimentaci\u00f3n del cuestionario, si bien este derecho no podr\u00e1 fundarse en el desconocimiento por parte de la Aseguradora de datos sobre el estado de salud del Tomador no incluidos en las preguntas anteriores.<\/div><div id=\"field_51_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Si existiera dolo o culpa grave en la cumplimentaci\u00f3n de este cuestionario, SegurCaixa Adeslas quedar\u00e1 en todo caso y en adelante liberada de las obligaciones que para ella establece la p\u00f3liza de seguro (Art. 10 Ley de Contrato de Seguro)<\/div><fieldset id=\"field_51_129\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Protecci\u00f3n de datos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_51_129'><div class='gchoice gchoice_51_129_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_129.1' type='checkbox'  value='He le\u00eddo y aceptado la &lt;a href=&quot;https:\/\/insbrok.com\/es\/politica-de-privacidad-y-proteccion-de-datos\/&quot; target=&quot;_blank&quot;&gt;pol\u00edtica de protecci\u00f3n de datos&lt;\/a&gt;'  id='choice_51_129_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_129_1' id='label_51_129_1' class='gform-field-label gform-field-label--type-inline'>He le\u00eddo y aceptado la <a href=\"https:\/\/insbrok.com\/es\/politica-de-privacidad-y-proteccion-de-datos\/\" target=\"_blank\">pol\u00edtica de protecci\u00f3n de datos<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_130\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Renovaciones y devoluciones<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_51_130'><div class='gchoice gchoice_51_130_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_130.1' type='checkbox'  value='Entiendo que, como exige la legislaci\u00f3n espa\u00f1ola, el contrato de seguro se renovar\u00e1 autom\u00e1ticamente cada a\u00f1o, a menos que yo comunique lo contrario por escrito al menos 30 d\u00edas antes de la fecha de renovaci\u00f3n. Tambi\u00e9n reconozco que los reembolsos s\u00f3lo est\u00e1n disponibles en caso de denegaci\u00f3n del visado, previa presentaci\u00f3n de una carta legal de denegaci\u00f3n, y se basar\u00e1n en los meses de cobertura. '  id='choice_51_130_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_130_1' id='label_51_130_1' class='gform-field-label gform-field-label--type-inline'>Entiendo que, como exige la legislaci\u00f3n espa\u00f1ola, el contrato de seguro se renovar\u00e1 autom\u00e1ticamente cada a\u00f1o, a menos que yo comunique lo contrario por escrito al menos 30 d\u00edas antes de la fecha de renovaci\u00f3n. Tambi\u00e9n reconozco que los reembolsos s\u00f3lo est\u00e1n disponibles en caso de denegaci\u00f3n del visado, previa presentaci\u00f3n de una carta legal de denegaci\u00f3n, y se basar\u00e1n en los meses de cobertura. <\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_48\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_48' id='input_51_48_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_51_48_Container' class='gfield_signature_container' style='height:180px; width:300px; ' ><canvas id=\"input_51_48\" width=\"300\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/insbrok.com\/wp-content\/plugins\/formecho-signature-add-on\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_51_48_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id='input_51_48_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' role='button' tabindex='0' aria-label='Clear Signature' \/><\/div><input type='hidden' id='input_51_48_data' name='input_51_48_data' value=''><\/div><\/div><\/fieldset><div id=\"field_51_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_92'>QR entry<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_51_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_93\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_93'>affwp_ref<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_51_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_94\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_94'>Affiliate ID<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_51_94' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_125'>statsEntry<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_51_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_101\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_101'>h1<\/label><div class='ginput_container ginput_container_number'><input name='input_101' id='input_51_101' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_102\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_102'>h2<\/label><div class='ginput_container ginput_container_number'><input name='input_102' id='input_51_102' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_103\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_103'>h3<\/label><div class='ginput_container ginput_container_number'><input name='input_103' id='input_51_103' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_104\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_104'>h4<\/label><div class='ginput_container ginput_container_number'><input name='input_104' id='input_51_104' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_105\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_105'>h5<\/label><div class='ginput_container ginput_container_number'><input name='input_105' id='input_51_105' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_106\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_106'>h6<\/label><div class='ginput_container ginput_container_number'><input name='input_106' id='input_51_106' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_107\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_107'>w1<\/label><div class='ginput_container ginput_container_number'><input name='input_107' id='input_51_107' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_108\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_108'>w2<\/label><div class='ginput_container ginput_container_number'><input name='input_108' id='input_51_108' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_109\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_109'>w3<\/label><div class='ginput_container ginput_container_number'><input name='input_109' id='input_51_109' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_110\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_110'>w4<\/label><div class='ginput_container ginput_container_number'><input name='input_110' id='input_51_110' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_111\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_111'>w5<\/label><div class='ginput_container ginput_container_number'><input name='input_111' id='input_51_111' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_51_112\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_112'>w6<\/label><div class='ginput_container ginput_container_number'><input name='input_112' id='input_51_112' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_51_114\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth1<\/legend><div id='input_51_114' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_114_2_container'>\n                                            <label for='input_51_114_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_114[]' id='input_51_114_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_114_1_container'>\n                                        <label for='input_51_114_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_114[]' id='input_51_114_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_114_3_container'>\n                                            <label for='input_51_114_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_114[]' id='input_51_114_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_51_115\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth2<\/legend><div id='input_51_115' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_115_2_container'>\n                                            <label for='input_51_115_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_115[]' id='input_51_115_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_115_1_container'>\n                                        <label for='input_51_115_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_115[]' id='input_51_115_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_115_3_container'>\n                                            <label for='input_51_115_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_115[]' id='input_51_115_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_51_116\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth3<\/legend><div id='input_51_116' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_116_2_container'>\n                                            <label for='input_51_116_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_116[]' id='input_51_116_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_116_1_container'>\n                                        <label for='input_51_116_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_116[]' id='input_51_116_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_116_3_container'>\n                                            <label for='input_51_116_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_116[]' id='input_51_116_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_51_117\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth4<\/legend><div id='input_51_117' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_117_2_container'>\n                                            <label for='input_51_117_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_117[]' id='input_51_117_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_117_1_container'>\n                                        <label for='input_51_117_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_117[]' id='input_51_117_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_117_3_container'>\n                                            <label for='input_51_117_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_117[]' id='input_51_117_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_51_118\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth5<\/legend><div id='input_51_118' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_118_2_container'>\n                                            <label for='input_51_118_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_118[]' id='input_51_118_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_118_1_container'>\n                                        <label for='input_51_118_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_118[]' id='input_51_118_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_118_3_container'>\n                                            <label for='input_51_118_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_118[]' id='input_51_118_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><fieldset id=\"field_51_119\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >birth6<\/legend><div id='input_51_119' class='ginput_container ginput_complex gform-grid-row'>\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_51_119_2_container'>\n                                            <label for='input_51_119_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>D\u00eda<\/label>\n                                            <input type='number' maxlength='2' name='input_119[]' id='input_51_119_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_51_119_1_container'>\n                                        <label for='input_51_119_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Mes<\/label>\n                                        <input type='number' maxlength='2' name='input_119[]' id='input_51_119_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_51_119_3_container'>\n                                            <label for='input_51_119_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>A\u00f1o<\/label>\n                                            <input type='number' maxlength='4' name='input_119[]' id='input_51_119_3' value=''   aria-required='false'   placeholder='AAAA' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                    <\/div><\/fieldset><div id=\"field_51_121\" class=\"gfield gfield--type-uid gfield--input-type-uid gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_51_121'>Order nr<\/label><div class='ginput_container ginput_container_hidden'><input name='input_121' id='input_51_121' type='hidden' value=''  \/><\/div><\/div><div id=\"field_51_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_100'>Compa\u00f1ia<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_51_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_133\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_133'>Language<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_51_133' type='text' value='en' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_357\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_51_357'>Exclude Workflow<\/label><div class='ginput_container ginput_container_text'><input name='input_357' id='input_51_357' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_134\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_134' id='input_51_134' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='https:\/\/insbrok.com\/es\/wp-json\/wp\/v2\/pages\/4329' \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_51' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' 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