{"id":891,"date":"2023-12-03T23:35:18","date_gmt":"2023-12-04T05:35:18","guid":{"rendered":"https:\/\/radiologiadentec.com\/?page_id=891"},"modified":"2023-12-03T23:35:19","modified_gmt":"2023-12-04T05:35:19","slug":"formulario","status":"publish","type":"page","link":"https:\/\/radiologiadentec.com\/index.php\/formulario\/","title":{"rendered":"Referencia para Solicitud de Servicio"},"content":{"rendered":"<div class=\"wpforms-container wpforms-block wpforms-block-4364c6f9-7a16-48dd-a273-1e1c4183f8d8\" id=\"wpforms-879\"><form id=\"wpforms-form-879\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"879\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/891\" data-token=\"84c24e2e0c823a6191df9dafef18d2dd\"><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-879-field_0-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"0\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_0\">Nombre del Paciente <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-879-field_0\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][0]\" required><\/div><div id=\"wpforms-879-field_3-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_3\">Nombre del Doctor(a) <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-879-field_3\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][3][first]\" required><label for=\"wpforms-879-field_3\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-879-field_3-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][3][last]\" placeholder=\"C\u00f3digo de Profesional\" required><label for=\"wpforms-879-field_3-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Apellidos<\/label><\/div><\/div><\/div><div id=\"wpforms-879-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_11\">Tel\u00e9fono de contacto <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-879-field_11\" class=\"wpforms-field-large wpforms-field-required wpforms-limit-characters-enabled\" data-form-id=\"879\" data-field-id=\"11\" data-text-limit=\"8\" name=\"wpforms[fields][11]\" placeholder=\"XXXX-XXXX\" maxlength=\"8\" required><\/div><div id=\"wpforms-879-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_1\">Correo electr\u00f3nico al cual enviar el servicio solicitado <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-879-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-879-field_2-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_2\">Diagn\u00f3stico Cl\u00ednico<\/label><textarea id=\"wpforms-879-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" ><\/textarea><\/div><div id=\"wpforms-879-field_8-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_8\">Radiograf\u00edas Digitales<\/label><ul id=\"wpforms-879-field_8\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_4\" name=\"wpforms[fields][8][]\" value=\"Rx Panor\u00e1mica\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_4\">Rx Panor\u00e1mica<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_5\" name=\"wpforms[fields][8][]\" value=\"Rx ATM (Boca Abierta)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_5\">Rx ATM (Boca Abierta)<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_6\" name=\"wpforms[fields][8][]\" value=\"Rx ATM (Boca Cerrada)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_6\">Rx ATM (Boca Cerrada)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_7\" name=\"wpforms[fields][8][]\" value=\"Rx Lateral de Cr\u00e1neo Cefalom\u00e9trica\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_7\">Rx Lateral de Cr\u00e1neo Cefalom\u00e9trica<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_8\" name=\"wpforms[fields][8][]\" value=\"Rx Frontal Cefalom\u00e9trica (A-P)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_8\">Rx Frontal Cefalom\u00e9trica (A-P)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_9\" name=\"wpforms[fields][8][]\" value=\"Rx Frontal Cefalom\u00e9trica (P-A)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_9\">Rx Frontal Cefalom\u00e9trica (P-A)<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_10\" name=\"wpforms[fields][8][]\" value=\"Rx Senos Paranasales\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_10\">Rx Senos Paranasales<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_11\" name=\"wpforms[fields][8][]\" value=\"Rx Waters\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_11\">Rx Waters<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_12\" name=\"wpforms[fields][8][]\" value=\"Rx Submentovertex\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_12\">Rx Submentovertex<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_8_13\" name=\"wpforms[fields][8][]\" value=\"Rx Mano Carpal\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_8_13\">Rx Mano Carpal<\/label><\/li><\/ul><\/div><div id=\"wpforms-879-field_9-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-2-columns\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_9\">Tomograf\u00edas Volum\u00e9tricas<\/label><ul id=\"wpforms-879-field_9\"><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_4\" name=\"wpforms[fields][9][]\" value=\"Sextante*\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_4\">Sextante*<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_5\" name=\"wpforms[fields][9][]\" value=\"Maxilar Completa\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_5\">Maxilar Completa<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_6\" name=\"wpforms[fields][9][]\" value=\"Mandibular Completa\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_6\">Mandibular Completa<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_7\" name=\"wpforms[fields][9][]\" value=\"Bimaxilar (Mand\u00edbula y Maxila)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_7\">Bimaxilar (Mand\u00edbula y Maxila)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_8\" name=\"wpforms[fields][9][]\" value=\"Bimaxilar Completo (Mand\u00edbula, Maxila y ATM)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_8\">Bimaxilar Completo (Mand\u00edbula, Maxila y ATM)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_9\" name=\"wpforms[fields][9][]\" value=\"Ramas Mandibulares Completas\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_9\">Ramas Mandibulares Completas<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_10\" name=\"wpforms[fields][9][]\" value=\"V\u00e9rtebras Cervicales\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_10\">V\u00e9rtebras Cervicales<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_11\" name=\"wpforms[fields][9][]\" value=\"ATM\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_11\">ATM<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_12\" name=\"wpforms[fields][9][]\" value=\"Reporte Radiol\u00f3gico (Costo adicional)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_12\">Reporte Radiol\u00f3gico (Costo adicional)<\/label><\/li><li class=\"choice-13 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_13\" name=\"wpforms[fields][9][]\" value=\"Tomograf\u00eda con Programa\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_13\">Tomograf\u00eda con Programa<\/label><\/li><li class=\"choice-14 depth-1\"><input type=\"checkbox\" id=\"wpforms-879-field_9_14\" name=\"wpforms[fields][9][]\" value=\"Archivos DICOM\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-879-field_9_14\">Archivos DICOM<\/label><\/li><\/ul><\/div><div id=\"wpforms-879-field_10-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-879-field_10\">*En caso de haber seleccionado Tomograf\u00eda de Sextante, por favor indique las piezas a estudiar:<\/label><textarea id=\"wpforms-879-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" ><\/textarea><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-recaptcha-container wpforms-is-recaptcha wpforms-is-recaptcha-type-v3\" ><input type=\"hidden\" name=\"wpforms[recaptcha]\" value=\"\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"879\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-879\" class=\"wpforms-submit\" data-alt-text=\"Enviando...\" data-submit-text=\"Enviar Formulario\" aria-live=\"assertive\" value=\"wpforms-submit\">Enviar Formulario<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/radiologiadentec.com\/wp-content\/plugins\/wpforms-lite\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Cargando\"><\/div><\/form><\/div>  <!-- .wpforms-container 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