{"id":2021,"date":"2023-11-03T20:03:23","date_gmt":"2023-11-03T20:03:23","guid":{"rendered":"https:\/\/rsqme.net\/?page_id=2021"},"modified":"2023-11-03T20:10:20","modified_gmt":"2023-11-03T20:10:20","slug":"motif-request","status":"publish","type":"page","link":"https:\/\/rsqme.net\/es\/motif-request\/","title":{"rendered":"MOTIF REQUEST"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"2021\" class=\"elementor elementor-2021\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-0006f98 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"0006f98\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-010e1d2\" data-id=\"010e1d2\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-13974c2 elementor-widget elementor-widget-heading\" data-id=\"13974c2\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-xl\">MOTIF REQUEST FORM<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-65cbaab elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"65cbaab\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-68d89c5\" data-id=\"68d89c5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-2604cc5 elementor-widget elementor-widget-spacer\" data-id=\"2604cc5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-c80d86f elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c80d86f\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-427b1ea\" data-id=\"427b1ea\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-7315f5f elementor-widget elementor-widget-wp-widget-forminator_widget\" data-id=\"7315f5f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-forminator_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"forminator-ui forminator-custom-form forminator-custom-form-2009 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2009\" data-uid=\"69f5cd43b5ad7\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-2009\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2009 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"2009\"\r\n\t\t\t\t data-color-option=\"default\" data-design=\"default\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"69f5cd43b5ad7\" action=\"\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69f5cd43b5ad7\" id=\"forminator-field-name-1_69f5cd43b5ad7-label\" class=\"forminator-label\">Nombre Completo de Mam\u00e1 <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_69f5cd43b5ad7\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69f5cd43b5ad7\" id=\"forminator-field-email-1_69f5cd43b5ad7-label\" class=\"forminator-label\">Correo Electr\u00f3nico <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69f5cd43b5ad7\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69f5cd43b5ad7\" id=\"forminator-field-phone-1_69f5cd43b5ad7-label\" class=\"forminator-label\">N\u00famero de Tel\u00e9fono <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69f5cd43b5ad7\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6\"><label for=\"forminator-field-date-2\" id=\"forminator-field-date-2-label\" class=\"forminator-label\">Mom&#039;s Birth Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-2-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-month_69f5cd43b5ad7\" class=\"forminator-label\">Month <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-2-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-month_69f5cd43b5ad7\" class=\"forminator-input\" data-field=\"month\" data-format=\"mm\/dd\/yy\" data-parent=\"date-2\" \/><\/div><\/div><div id=\"date-2-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-day_69f5cd43b5ad7\" class=\"forminator-label\">Day <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-2-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-day_69f5cd43b5ad7\" class=\"forminator-input\" data-field=\"day\" data-format=\"mm\/dd\/yy\" data-parent=\"date-2\" \/><\/div><\/div><div id=\"date-2-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-year_69f5cd43b5ad7\" class=\"forminator-label\">Year <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-2-year\" placeholder=\"\" id=\"forminator-field-date-2-year_69f5cd43b5ad7\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"mm\/dd\/yy\" data-parent=\"date-2\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69f5cd43b5ad7\" id=\"forminator-field-date-1-picker_69f5cd43b5ad7-label\" class=\"forminator-label\">Baby&#039;s Due Date <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-picker_69f5cd43b5ad7\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-4\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field required\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-69f5cd43b5ad7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-69f5cd43b5ad7-label\" class=\"forminator-label\">Select your Insurance <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-checkbox-4-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Amerigroup\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"yes\" id=\"forminator-field-checkbox-4-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Amerigroup<\/span><\/label><label id=\"forminator-field-checkbox-4-2-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-2-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Parkland\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"no\" id=\"forminator-field-checkbox-4-2-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-2-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Parkland<\/span><\/label><label id=\"forminator-field-checkbox-4-3-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-3-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Molina\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Molina\" id=\"forminator-field-checkbox-4-3-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-3-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Molina<\/span><\/label><label id=\"forminator-field-checkbox-4-4-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-4-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Aetna Better Health\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Aetna-Better\" id=\"forminator-field-checkbox-4-4-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-4-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Aetna Better Health<\/span><\/label><label id=\"forminator-field-checkbox-4-5-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-5-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Superior\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Superior\" id=\"forminator-field-checkbox-4-5-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-5-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Superior<\/span><\/label><label id=\"forminator-field-checkbox-4-6-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-6-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Cook Children&#039;s\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Cook-Children&#039;s\" id=\"forminator-field-checkbox-4-6-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-6-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cook Children's<\/span><\/label><label id=\"forminator-field-checkbox-4-7-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-7-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"RightCare-Scott and White\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Rightcare\" id=\"forminator-field-checkbox-4-7-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-7-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">RightCare-Scott and White<\/span><\/label><label id=\"forminator-field-checkbox-4-8-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-8-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Firstcare\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Firstcare\" id=\"forminator-field-checkbox-4-8-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-8-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Firstcare<\/span><\/label><label id=\"forminator-field-checkbox-4-9-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-9-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Texas Medicaid\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"TMHP\" id=\"forminator-field-checkbox-4-9-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-9-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Texas Medicaid<\/span><\/label><label id=\"forminator-field-checkbox-4-10-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-10-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Texas Children&#039;s\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Texas-Children&#039;s\" id=\"forminator-field-checkbox-4-10-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-10-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Texas Children's<\/span><\/label><label id=\"forminator-field-checkbox-4-11-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-11-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"CHIP\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"CHIP\" id=\"forminator-field-checkbox-4-11-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-11-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">CHIP<\/span><\/label><label id=\"forminator-field-checkbox-4-12-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-4-12-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Commercial Insurance\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Commercial-Insurance\" id=\"forminator-field-checkbox-4-12-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-4-12-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Commercial Insurance<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_69f5cd43b5ad7\" id=\"forminator-field-phone-3_69f5cd43b5ad7-label\" class=\"forminator-label\">Numero de Identificacion de Seguro <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_69f5cd43b5ad7\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-3\"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f5cd43b5ad7\" id=\"forminator-field-name-2_69f5cd43b5ad7-label\" class=\"forminator-label\">Informacion sobre su clinica de OBGYN <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69f5cd43b5ad7\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-2_69f5cd43b5ad7-description\" \/><span id=\"forminator-field-name-2_69f5cd43b5ad7-description\" class=\"forminator-description\">Nombre de la Clinica<\/span><\/div><\/div><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-3\"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69f5cd43b5ad7\" id=\"forminator-field-name-4_69f5cd43b5ad7-label\" class=\"forminator-label\">\u200e<\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69f5cd43b5ad7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-4_69f5cd43b5ad7-description\" \/><span id=\"forminator-field-name-4_69f5cd43b5ad7-description\" class=\"forminator-description\">Ciudad<\/span><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-3\"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69f5cd43b5ad7\" id=\"forminator-field-phone-2_69f5cd43b5ad7-label\" class=\"forminator-label\">\u200e<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_69f5cd43b5ad7\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" aria-describedby=\"forminator-field-phone-2_69f5cd43b5ad7-description\" \/><span id=\"forminator-field-phone-2_69f5cd43b5ad7-description\" class=\"forminator-description\">Numero de Telefono de su Clinica<\/span><\/div><\/div><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-3\"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69f5cd43b5ad7\" id=\"forminator-field-name-3_69f5cd43b5ad7-label\" class=\"forminator-label\">\u200e<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69f5cd43b5ad7\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" autocomplete=\"name\" aria-describedby=\"forminator-field-name-3_69f5cd43b5ad7-description\" \/><span id=\"forminator-field-name-3_69f5cd43b5ad7-description\" class=\"forminator-description\">Nombre de su Doctor<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-69f5cd43b5ad7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-69f5cd43b5ad7-label\" class=\"forminator-label\">ME GUSTAR\u00cdA: (TODOS LOS ART\u00cdCULOS NO TIENEN COSTO CON MEDICAID)<\/span><label id=\"forminator-field-checkbox-2-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-2-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"EXTRACTOR DE LECHE\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"BREAST-PUMP\" id=\"forminator-field-checkbox-2-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-2-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">EXTRACTOR DE LECHE<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-8\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-8-69f5cd43b5ad7-label\"><label id=\"forminator-field-checkbox-8-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-8-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"MONITOR DE PRESI\u00d3N ARTERIAL\"><input type=\"checkbox\" name=\"checkbox-8[]\" value=\"BLOOD-PRESSURE-MONITOR\" id=\"forminator-field-checkbox-8-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-8-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">MONITOR DE PRESI\u00d3N ARTERIAL<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-5\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-5-69f5cd43b5ad7-label\"><label id=\"forminator-field-checkbox-5-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-5-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"BANDA DE SOPORTE (Durante el embarazo)\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"SUPPORT-BAND-(-During-Pregnancy-)\" id=\"forminator-field-checkbox-5-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-5-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">BANDA DE SOPORTE (Durante el embarazo)<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-69f5cd43b5ad7-label\" aria-describedby=\"forminator-radiogroup-radio-1-69f5cd43b5ad7-description\"><span id=\"forminator-radiogroup-radio-1-69f5cd43b5ad7-label\" class=\"forminator-label\">Beneficios de las bandas de soporte:<\/span><span id=\"forminator-radiogroup-radio-1-69f5cd43b5ad7-description\" class=\"forminator-description\">\u2022\tHelps to disperse the weight of your growing baby \u2022\tIncreases stability \u2022\tAlleviates pain \u2022\tDecreases SI joint pain \u2022\tLowers round ligament pain \u2022\tReduces pressure on the bladder \u2022\tSupports prenatal activities or exercises \u2022\tCorrects posture \u2022\tReduces sciatica<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-2009__field--select-1_69f5cd43b5ad7\" id=\"forminator-form-2009__field--select-1_69f5cd43b5ad7-label\" class=\"forminator-label\">Tama\u00f1o de la banda de soporte<\/label><select  id=\"forminator-form-2009__field--select-1_69f5cd43b5ad7\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-1\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2009__field--select-1_69f5cd43b5ad7-label\" aria-describedby=\"forminator-form-2009__field--select-1_69f5cd43b5ad7-description\"><option value=\"XS-(-Pre-Pregnancy-Pant-Size:-2-)\"  data-calculation=\"0\">XS (Talla de pantal\u00f3n antes del embarazo: 2)<\/option><option value=\"S-(-Pre-Pregnancy-Pant-Size:-4-)\"  data-calculation=\"0\">S (Talla de pantal\u00f3n antes del embarazo: 4)<\/option><option value=\"m-pre-pregnancy-pant-size-6---12-\"  data-calculation=\"0\">M (Talla de pantal\u00f3n antes del embarazo: 6-12)<\/option><option value=\"l-pre-pregnancy-pant-size-14---18-\"  data-calculation=\"0\">L (Talla de pantal\u00f3n antes del embarazo: 14-20)<\/option><option value=\"xl-pre-pregnancy-pant-size-20---26-\"  data-calculation=\"0\">XL (Talla de pantal\u00f3n antes del embarazo: m\u00e1s de 20)<\/option><\/select><span id=\"forminator-form-2009__field--select-1_69f5cd43b5ad7-description\" class=\"forminator-description\">S\u00f3lo disponible durante el embarazo*<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-6\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-6-69f5cd43b5ad7-label\"><label id=\"forminator-field-checkbox-6-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-6-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"MEDIAS DE COMPRESI\u00d3N\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"COMPRESSION-SOCKS\" id=\"forminator-field-checkbox-6-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-6-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">MEDIAS DE COMPRESI\u00d3N<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-69f5cd43b5ad7-label\" aria-describedby=\"forminator-radiogroup-radio-2-69f5cd43b5ad7-description\"><span id=\"forminator-radiogroup-radio-2-69f5cd43b5ad7-label\" class=\"forminator-label\">Beneficios de las medias de compresi\u00f3n:<\/span><span id=\"forminator-radiogroup-radio-2-69f5cd43b5ad7-description\" class=\"forminator-description\">\u2022 Previene la hinchaz\u00f3n \u2022 Reduce las molestias \u2022 Aumenta la circulaci\u00f3n sangu\u00ednea \u2022 Previene o minimiza el riesgo de varices y ara\u00f1as vasculares \u2022 Ayuda a prevenir co\u00e1gulos sangu\u00edneos \u2022 Reduce el riesgo de trombosis venosa profunda (TVP) \u2022 Ayuda a soportar largos d\u00edas de pie \u2022 Aumenta la comodidad general durante todo el d\u00eda<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-2009__field--select-2_69f5cd43b5ad7\" id=\"forminator-form-2009__field--select-2_69f5cd43b5ad7-label\" class=\"forminator-label\">Talla de medias de compresi\u00f3n<\/label><select  id=\"forminator-form-2009__field--select-2_69f5cd43b5ad7\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2009__field--select-2_69f5cd43b5ad7-label\"><option value=\"\u200e\"  data-calculation=\"0\">\u200e<\/option><option value=\"S-(Ankle:-6.5&quot;---8.5&quot;---Calf:-11&quot;---16.5-&quot;)\"  data-calculation=\"0\">S (Tobillo: 6,5\" - 8,5\" \/ Pantorrilla: 11\" - 16,5\")<\/option><option value=\"M-(Ankle:-8&quot;---10&quot;---Calf:-12&quot;---17.5-&quot;)\"  data-calculation=\"0\">M (Tobillo: 8\" - 10\" \/ Pantorrilla: 12\" - 17,5 \")<\/option><option value=\"L-(Ankle:-9&quot;---11.5&quot;---Calf:-13&quot;---19-&quot;)\"  data-calculation=\"0\">L (Tobillo: 9\" - 11.5\" \/ Pantorrilla: 13\" - 19 \")<\/option><option value=\"XL-(Ankle:-11&quot;---15&quot;---Calf:-17&quot;---23-&quot;)\"  data-calculation=\"0\">XL (Tobillo: 11\" - 15\" \/ Pantorrilla: 17\" - 23 \")<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-7\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-7-69f5cd43b5ad7-label\"><label id=\"forminator-field-checkbox-7-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-7-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"PRENDA DE SOPORTE PARA LA RECUPERACI\u00d3N POSPARTO\"><input type=\"checkbox\" name=\"checkbox-7[]\" value=\"POSTPARTUM-RECOVERY-SUPPORT-GARMENT\" id=\"forminator-field-checkbox-7-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-7-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">PRENDA DE SOPORTE PARA LA RECUPERACI\u00d3N POSPARTO<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-12\"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-69f5cd43b5ad7-label\" aria-describedby=\"forminator-radiogroup-radio-3-69f5cd43b5ad7-description\"><span id=\"forminator-radiogroup-radio-3-69f5cd43b5ad7-label\" class=\"forminator-label\">Beneficios de la prenda de soporte para la recuperaci\u00f3n posparto:<\/span><span id=\"forminator-radiogroup-radio-3-69f5cd43b5ad7-description\" class=\"forminator-description\">\u2022 Proporciona una compresi\u00f3n y un soporte suaves para reducir la hinchaz\u00f3n, el dolor y el malestar \u2022 Estabiliza el abdomen, la espalda baja y las caderas para mejorar la postura \u2022 Aumenta la movilidad general \u2022 Aprieta y tonifica el abdomen, las caderas, la cintura, la pelvis y la espalda baja<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-form-2009__field--select-3_69f5cd43b5ad7\" id=\"forminator-form-2009__field--select-3_69f5cd43b5ad7-label\" class=\"forminator-label\">Talla de la prenda de apoyo para la recuperaci\u00f3n posparto<\/label><select  id=\"forminator-form-2009__field--select-3_69f5cd43b5ad7\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-2009__field--select-3_69f5cd43b5ad7-label\"><option value=\"\u200e\"  data-calculation=\"0\">\u200e<\/option><option value=\"S-(-Pre-Pregnancy-Pant-Size:-2---4-)\"  data-calculation=\"0\">S (Talla de pantal\u00f3n antes del embarazo: 0-4)<\/option><option value=\"M-(-Pre-Pregnancy-Pant-Size:-6---8-)\"  data-calculation=\"0\">M (Talla de pantal\u00f3n antes del embarazo: 6-8)<\/option><option value=\"L-(-Pre-Pregnancy-Pant-Size:-10---12-)\"  data-calculation=\"0\">L (Talla de pantal\u00f3n antes del embarazo: 10-12)<\/option><option value=\"XL-(-Pre-Pregnancy-Pant-Size:-14---16-)\"  data-calculation=\"0\">XL (Talla de pantal\u00f3n antes del embarazo: 14-16)<\/option><option value=\"2XL-(-Pre-Pregnancy-Pant-Size:-18---20-)\"  data-calculation=\"0\">XL ( Pre-Pregnancy Pant Size: 14 - 16 )<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-69f5cd43b5ad7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-69f5cd43b5ad7-label\" class=\"forminator-label\">Lenguaje de Preferencia<\/span><label id=\"forminator-field-checkbox-1-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-1-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Ingles\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"english\" id=\"forminator-field-checkbox-1-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-1-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ingles<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-1-2-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Espa\u00f1ol\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"spanish\" id=\"forminator-field-checkbox-1-2-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-1-2-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Espa\u00f1ol<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><h3 class=\"forminator-subtitle\">Proporcione una buena direcci\u00f3n postal para la entrega de productos:<\/h3><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12\"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69f5cd43b5ad7\" id=\"forminator-field-address-1-street_address_69f5cd43b5ad7-label\" class=\"forminator-label\">Direcci\u00f3n <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69f5cd43b5ad7\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69f5cd43b5ad7\" id=\"forminator-field-address-1-address_line_69f5cd43b5ad7-label\" class=\"forminator-label\">Apartamento, suite, etc.<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69f5cd43b5ad7\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69f5cd43b5ad7\" id=\"forminator-field-address-1-city_69f5cd43b5ad7-label\" class=\"forminator-label\">Ciudad <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69f5cd43b5ad7\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_69f5cd43b5ad7\" id=\"forminator-field-address-1-state_69f5cd43b5ad7-label\" class=\"forminator-label\">Estado <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_69f5cd43b5ad7\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69f5cd43b5ad7\" id=\"forminator-field-address-1-zip_69f5cd43b5ad7-label\" class=\"forminator-label\">ZIP \/ Codigo Postal <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_69f5cd43b5ad7\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-3-69f5cd43b5ad7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-69f5cd43b5ad7-label\" class=\"forminator-label\">Entiendo que Medicaid pagar\u00e1 por un extractor de leche el\u00e9ctrico. Cualquier otro extractor de leche el\u00e9ctrico que reciba ser\u00e1 un gasto de bolsillo.**<\/span><label id=\"forminator-field-checkbox-3-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-3-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Reconozco.\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"i-acknowledge\" id=\"forminator-field-checkbox-3-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-3-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Reconozco.<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12\"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px dashed #17a8e3;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-9\" class=\"forminator-field-checkbox forminator-col forminator-col-12\"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-9-69f5cd43b5ad7-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-9-69f5cd43b5ad7-label\" class=\"forminator-label\">Al marcar esta casilla, acepta recibir actualizaciones por SMS sobre su pedido. Pueden aplicarse tarifas por mensajes y datos. Para cancelar su suscripci\u00f3n en cualquier momento, responda \"STOP\" a cualquiera de nuestros mensajes.<\/span><label id=\"forminator-field-checkbox-9-1-69f5cd43b5ad7-label\" for=\"forminator-field-checkbox-9-1-69f5cd43b5ad7\" class=\"forminator-checkbox\" title=\"Acepto\"><input type=\"checkbox\" name=\"checkbox-9[]\" value=\"i-acknowledge\" id=\"forminator-field-checkbox-9-1-69f5cd43b5ad7\" aria-labelledby=\"forminator-field-checkbox-9-1-69f5cd43b5ad7-label\" data-calculation=\"0\"  \/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Acepto<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f5cd43b5ad7\" id=\"forminator-field-text-1_69f5cd43b5ad7-label\" class=\"forminator-label\">Please expect a text from RSQ Medical Equipment within 24 hours regarding your request. To opt out of texting, please indicate other preferred method of contact:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69f5cd43b5ad7\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">ENVIAR APLICACION<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"b006da8f30\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/2021\" \/><input type=\"hidden\" name=\"form_id\" value=\"2009\"><input type=\"hidden\" name=\"page_id\" value=\"2021\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/rsqme.net\/es\/motif-request\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-a4632e7 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a4632e7\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ec51bbb\" data-id=\"ec51bbb\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-4c044c0 elementor-widget elementor-widget-spacer\" data-id=\"4c044c0\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e93c389 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e93c389\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-d5a64ce\" data-id=\"d5a64ce\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9362153 elementor-widget elementor-widget-heading\" data-id=\"9362153\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\"><a href=\"https:\/\/www.facebook.com\/RSQ-Medical-Equipment-110576630747809\">\u00a1Danos like en facebook!<\/a><\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b8c3545 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b8c3545\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-9bb21b6\" data-id=\"9bb21b6\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0f75fc5 elementor-view-default elementor-widget elementor-widget-icon\" data-id=\"0f75fc5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<a class=\"elementor-icon\" href=\"https:\/\/www.facebook.com\/RSQ-Medical-Equipment-110576630747809\">\n\t\t\t<i aria-hidden=\"true\" class=\"fab 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