{"id":768,"date":"2023-03-04T06:58:40","date_gmt":"2023-03-04T06:58:40","guid":{"rendered":"https:\/\/helphomecare.net\/?page_id=768"},"modified":"2023-03-04T06:58:40","modified_gmt":"2023-03-04T06:58:40","slug":"formulario","status":"publish","type":"page","link":"https:\/\/helphomecare.net\/index.php\/formulario\/","title":{"rendered":"Formulario"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block\" id=\"wpforms-746\"><form id=\"wpforms-form-746\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"746\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/768\" data-token=\"b0162905cad66af319ced62b543018fa\" data-token-time=\"1777652136\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-746-field_7-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_7\">Fecha <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-746-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" placeholder=\"Ej. 02\/02\/2023\" step=\"any\" required><\/div><div id=\"wpforms-746-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\">Nombre <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-746-field_3\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][3][first]\" required><label for=\"wpforms-746-field_3\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-746-field_3-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][3][last]\" required><label for=\"wpforms-746-field_3-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/div><div id=\"wpforms-746-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_6\">Direcci\u00f3n  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-746-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" required><\/div><div id=\"wpforms-746-field_1-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_1\">Fecha de Nacimiento  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-746-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" step=\"any\" required><\/div><div id=\"wpforms-746-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_4\">Sexo <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-746-field_4\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][4]\" required><\/div><div id=\"wpforms-746-field_8-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_8\">Celular  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-746-field_8\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][8]\" step=\"any\" required><\/div><div id=\"wpforms-746-field_5-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_5\">Tel\u00e9fono  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-746-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" step=\"any\" required><\/div><div id=\"wpforms-746-field_9-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_9\">Medicaid<\/label><input type=\"text\" id=\"wpforms-746-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-746-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_10\">Medicare SNN<\/label><input type=\"text\" id=\"wpforms-746-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-746-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_11\">Idioma<\/label><input type=\"text\" id=\"wpforms-746-field_11\" class=\"wpforms-field-medium\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-746-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_12\">Contacto de Emergencia  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-746-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" required><\/div><div id=\"wpforms-746-field_13-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_13\">N\u00famero del contacto de emergencia  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"number\" id=\"wpforms-746-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" step=\"any\" required><\/div><div id=\"wpforms-746-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_14\">\u00bfEst\u00e1 recibiendo servicios en estos momentos? En caso que si, especifique el proveedor <\/label><input type=\"text\" id=\"wpforms-746-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-746-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_15\">Dificultades \/ Problemas del paciente <\/label><textarea id=\"wpforms-746-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/textarea><\/div><div id=\"wpforms-746-field_16-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_16\">Comentarios<\/label><textarea id=\"wpforms-746-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/textarea><\/div><div id=\"wpforms-746-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-746-field_17\">Referido por<\/label><input type=\"text\" id=\"wpforms-746-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><div class=\"wpforms-field-description\">Uso de Oficina Solamente<\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"746\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/helphomecare.net\/index.php\/wp-json\/wp\/v2\/pages\/768\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-746\" class=\"wpforms-submit\" data-alt-text=\"Enviando...\" data-submit-text=\"Aplicar\" aria-live=\"assertive\" value=\"wpforms-submit\">Aplicar<\/button><img decoding=\"async\" src=\"https:\/\/helphomecare.net\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container 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