{"id":50,"date":"2022-01-24T13:32:09","date_gmt":"2022-01-24T13:32:09","guid":{"rendered":"https:\/\/simonmed.wpengine.com\/?page_id=50"},"modified":"2022-09-30T10:32:27","modified_gmt":"2022-09-30T10:32:27","slug":"patient-information-form-spanish","status":"publish","type":"page","link":"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/","title":{"rendered":"Patient Information Form &#8211; Spanish"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"50\" class=\"elementor elementor-50\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-4ef05fb9 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"4ef05fb9\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-2ed1fc6a\" data-id=\"2ed1fc6a\" data-element_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-16f13314 elementor-widget elementor-widget-heading\" data-id=\"16f13314\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h1 class=\"elementor-heading-title elementor-size-default\">Patient Information Form - Spanish<\/h1>\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-4f91da4 mbl-mamography elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"4f91da4\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-d4437b2\" data-id=\"d4437b2\" data-element_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-230b3b7 text-link elementor-hidden-desktop elementor-hidden-tablet elementor-widget elementor-widget-button\" data-id=\"230b3b7\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"\/wp-content\/uploads\/2022\/02\/Patient_Information_Form_Spanish_Updated_July_20181.pdf\" target=\"_blank\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">descargar pdf<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-d239a04 elementor-hidden-mobile elementor-widget elementor-widget-html\" data-id=\"d239a04\" data-element_type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t<div class=\"form-wrap\">\r\n\r\n\r\n\t\t<div class=\"center\">\r\n\t\t\t<div class=\"padding-md-h padding-xl-v shift8-padding-xs-v\">\r\n\t\t\t\t\r\n    <div class=\"auth-form patient-info\" data-form=\"2018_patient_information_english\">\r\n\r\n  <div class=\"error-msg\"><\/div>\r\n\r\n  <form class=\"\" id=\"patient-info-form\" name=\"patient-info-form\" data-locale=\"eng\" action=\"#\" method=\"post\">\r\n\r\n\r\n    <div class=\"top-form\">\r\n      <div class=\"col col-1\/2\">\r\n        <div class=\"patient-info-image\"><img decoding=\"async\" class=\"lazy-load\" src=\"\/wp-content\/uploads\/2022\/02\/logo_withtag.png\" data-src=\"\/application\/themes\/simon_med\/img\/logo_withtag.png\" alt=\"SimonMed Logo\"><\/div>\r\n      <\/div>\r\n\r\n        <!-- ARRIVAL TIME -->\r\n        <div class=\"form-group field field-text col col-1\/4 \">\r\n          <div class=\"input-cont\">\r\n           <label class=\"control-label\" for=\"arrival-time\">Hora de llegada:<\/label>\r\n           <span><input name=\"arrival-time\" id=\"arrival-time\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n        <\/div>\r\n\r\n        <!-- MRN -->\r\n        <div class=\"form-group field field-text col col-1\/4 \">\r\n          <div class=\"input-cont\">\r\n           <label class=\"control-label\" for=\"mrn\">MRN:<\/label>\r\n           <span><input name=\"mrn\" id=\"mrn\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n        <\/div>\r\n\r\n    <\/div>\r\n    <div class=\"clear\"><\/div>\r\n\r\n\r\n    <h4 class=\"info-spacer\">\r\n\t\tInformaci\u00f3n del paciente \u2013 POR FAVOR EN LETRA DE MOLDE\r\n\r\n    <\/h4>\r\n\r\n    <!-- patient name -->\r\n    <div class=\"form-group field field-text col col-3\/4 \">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"patient-name\">Nombre del paciente (apellido, primer nombre):<\/label>\r\n       <span><input name=\"patient-name\" id=\"patient-name\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- gender -->\r\n    <div class=\"form-group field field-text col col-1\/4 \">\r\n      <div class=\"input-cont radio-buttons\">\r\n        <div class=\"radio-cont\">\r\n            <label>\r\n                <input type=\"radio\" name=\"gender\" value=\"male\"><span>Masculino <\/span>\r\n            <\/label>\r\n            <label>\r\n                <input type=\"radio\" name=\"gender\" value=\"female\"><span>Femenino<\/span><br>\r\n            <\/label>\r\n          <span class=\"spacer\"><\/span>\r\n        <\/div>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- patient name -->\r\n    <div class=\"form-group field field-text col col-1\/2 \">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"dob\">Fecha de nacimiento:<\/label>\r\n       <span><input name=\"dob\" id=\"dob\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- social security number-->\r\n    <div class=\"form-group field field-text col col-1\/2 \">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"soc\">N\u00famero de seguro social <span>(xxx-xx-xxxx)<\/span>  (opcional):<\/label>\r\n       <span><input name=\"soc\" id=\"soc\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- address -->\r\n    <div class=\"form-group field field-text col col-1\/2 \">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"address\">Direcci\u00f3n de correo:<\/label>\r\n       <span><input name=\"address\" id=\"address\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- city -->\r\n    <div class=\"form-group field field-text col col-1\/4\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"city\">Ciudad:<\/label>\r\n       <span><input name=\"city\" id=\"city\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- state -->\r\n    <div class=\"form-group field field-text col col-1\/4 selc-text \">\r\n      <div class=\"input-cont\">\r\n       <label class=\"\" for=\"shipping-state\">Estado:<\/label>\r\n       <select id=\"shipping-state\" required=\"\" tabindex=\"-1\" name=\"state\" title=\"\" class=\"select2-hidden-accessible\" aria-hidden=\"true\">\r\n                          <option value=\"\">--<\/option>\r\n                          <option value=\"AL\">AL<\/option>\r\n                          <option value=\"AK\">AK<\/option>\r\n                          <option value=\"AZ\">AZ<\/option>\r\n                          <option value=\"AR\">AR<\/option>\r\n                          <option value=\"CA\">CA<\/option>\r\n                          <option value=\"CO\">CO<\/option>\r\n                          <option value=\"CT\">CT<\/option>\r\n                          <option value=\"DE\">DE<\/option>\r\n                          <option value=\"DC\">DC<\/option>\r\n                          <option value=\"FL\">FL<\/option>\r\n                          <option value=\"GA\">GA<\/option>\r\n                          <option value=\"HI\">HI<\/option>\r\n                          <option value=\"ID\">ID<\/option>\r\n                          <option value=\"IL\">IL<\/option>\r\n                          <option value=\"IN\">IN<\/option>\r\n                          <option value=\"IA\">IA<\/option>\r\n                          <option value=\"KS\">KS<\/option>\r\n                          <option value=\"KY\">KY<\/option>\r\n                          <option value=\"LA\">LA<\/option>\r\n                          <option value=\"ME\">ME<\/option>\r\n                          <option value=\"MD\">MD<\/option>\r\n                          <option value=\"MA\">MA<\/option>\r\n                          <option value=\"MI\">MI<\/option>\r\n                          <option value=\"MN\">MN<\/option>\r\n                          <option value=\"MS\">MS<\/option>\r\n                          <option value=\"MO\">MO<\/option>\r\n                          <option value=\"MT\">MT<\/option>\r\n                          <option value=\"NE\">NE<\/option>\r\n                          <option value=\"NV\">NV<\/option>\r\n                          <option value=\"NH\">NH<\/option>\r\n                          <option value=\"NJ\">NJ<\/option>\r\n                          <option value=\"NM\">NM<\/option>\r\n                          <option value=\"NY\">NY<\/option>\r\n                          <option value=\"NC\">NC<\/option>\r\n                          <option value=\"ND\">ND<\/option>\r\n                          <option value=\"OH\">OH<\/option>\r\n                          <option value=\"OK\">OK<\/option>\r\n                          <option value=\"OR\">OR<\/option>\r\n                          <option value=\"PA\">PA<\/option>\r\n                          <option value=\"RI\">RI<\/option>\r\n                          <option value=\"SC\">SC<\/option>\r\n                          <option value=\"SD\">SD<\/option>\r\n                          <option value=\"TN\">TN<\/option>\r\n                          <option value=\"TX\">TX<\/option>\r\n                          <option value=\"UT\">UT<\/option>\r\n                          <option value=\"VT\">VT<\/option>\r\n                          <option value=\"VA\">VA<\/option>\r\n                          <option value=\"WA\">WA<\/option>\r\n                          <option value=\"WV\">WV<\/option>\r\n                          <option value=\"WI\">WI<\/option>\r\n                          <option value=\"WY\">WY<\/option>\r\n                  <\/select>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- zip -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"zip\">C\u00f3digo postal:<\/label>\r\n       <span><input name=\"zip\" id=\"zip\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- home number -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"home-number\">Tel\u00e9fono de casa# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\r\n       <span><input name=\"home-number\" data-name=\"home-number\" id=\"home-number\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- cell number -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"cell-number\">Celular# <span>(xxx-xxx-xxxx)<\/span>:<\/label>\r\n       <span><input name=\"cell-number\" data-name=\"cell-number\" id=\"cell-number\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Email -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"email\">Correo electr\u00f3nico:<\/label>\r\n       <span><input name=\"email\" id=\"email\" required=\"\" class=\"form-control\" value=\"\" type=\"email\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- emergency contact -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"emergency-contact\">Persona a contactar en emergencias:<\/label>\r\n       <span><input name=\"emergency-contact\" id=\"emergency-contact\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- emergency phone -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"emergency-phone\">Tel\u00e9fono de esta persona <span>(xxx-xxx-xxxx)<\/span>:<\/label>\r\n       <span><input name=\"emergency-phone\" id=\"emergency-phone\" data-name=\"emergency phone\" required=\"\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"clear\"><\/div>\r\n    <h4 class=\"info-spacer\">\r\n\t\tHistorial m\u00e9dico\r\n    <\/h4>\r\n\r\n    <!-- Medication Allergies -->\r\n    <div class=\"form-group field field-text col col-full\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"allergies\">Alergias conocidas:<\/label>\r\n       <span><input name=\"allergies\" id=\"allergies\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Current Medication -->\r\n    <div class=\"form-group field field-text col col-full\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"current-medication\">Medicamentos actuales:\t<\/label>\r\n       <span><input name=\"current-medication\" id=\"current-medication\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Pregnant -->\r\n    <div class=\"form-group field field-text col col-3\/5\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\">S\u00f3lo para MUJERES: \u00bfHay posibilidad de que pudiera estar embarazada?<\/label>\r\n       <div class=\"radio-cont\">\r\n           <input type=\"radio\" id=\"pregnant-yes\" name=\"pregnant\" value=\"yes\">\r\n           <label class=\"radio-label\" for=\"pregnant-yes\">S\u00cd<\/label>\r\n           <input type=\"radio\" id=\"pregnant-no\" name=\"pregnant\" value=\"no\">\r\n           <label class=\"radio-label\" for=\"pregnant-no\">NO<\/label><br>\r\n       <\/div>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- date of lmp -->\r\n    <div class=\"form-group field field-text col col-2\/5\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"lmp\">Fecha de \u00faltima menstruaci\u00f3n <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n       <span><input name=\"lmp\" id=\"lmp\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"clear\"><\/div>\r\n    <h4 class=\"info-spacer\">\r\n\t\tInformaci\u00f3n de Seguro\/Compensaci\u00f3n Laboral\/Garante de Seguro\r\n    <\/h4>\r\n\r\n    <!-- Primary Insur\/Work Comp-->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"insurance\">Seguro primario\/Compensaci\u00f3n laboral:<\/label>\r\n       <span><input name=\"insurance\" id=\"insurance\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Secondary Insurance -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"sec-insurance\">Seguro secundario:<\/label>\r\n       <span><input name=\"sec-insurance\" id=\"sec-insurance\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Date of Injury -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"date-injury\">Fecha de Herida<span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n       <span><input name=\"date-injury\" id=\"date-injury\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Insured (Insurance) -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n          <label class=\"control-label\" for=\"insured-insurance\">Asegurado:<\/label>\r\n          <span><input name=\"insured-insurance\" id=\"insured-insurance\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Insured dob -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n          <label class=\"control-label\" for=\"insured-dob\">Fecha de Nacimiento Asegurado:<\/span>:<\/label>\r\n          <span><input name=\"insured-dob\" id=\"insured-dob\" class=\"form-control date hasDatepicker\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Group# -->\r\n    <div class=\"form-group field field-text col col-1\/3\">\r\n      <div class=\"input-cont\">\r\n          <label class=\"control-label\" for=\"group-number\">Group#:<\/label>\r\n          <span><input name=\"group-number\" id=\"group-number\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Member ID# -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n          <label class=\"control-label\" for=\"member-id\">Identificaci\u00f3n #:<\/label>\r\n          <span><input name=\"member-id\" id=\"member-id\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Guarantor -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"guarantor\">Garante (Financieramente Responsable):<\/label>\r\n       <span><input name=\"guarantor\" id=\"guarantor\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Guarantor dob -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"guarantor-dob\">Fecha de Nacimiento del Garante <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n       <span><input name=\"guarantor-dob\" id=\"guarantor-dob\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Relation to patient -->\r\n    <div class=\"form-group field field-text col col-1\/2\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"relation-to-patient\">Relaci\u00f3n con el Paciente:\t<\/label>\r\n       <span><input name=\"relation-to-patient\" id=\"relation-to-patient\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Cell# -->\r\n    <div class=\"form-group field field-text col col-full\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"guarantor-cell-number\">Celular#  <span>(xxx-xxx-xxxx)<\/span>:<\/label>\r\n       <span><input name=\"guarantor-cell-number\" id=\"guarantor-cell-number\" class=\"form-control\" value=\"\" type=\"tel\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n      <!-- Guarantor Address -->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"guarantor-address\">Direcci\u00f3n de correo:\t<\/label>\r\n              <span><input name=\"guarantor-address\" id=\"guarantor-address\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n      <!-- Guarantor City -->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"guarantor-city\">Ciudad:<\/label>\r\n              <span><input name=\"guarantor-city\" id=\"guarantor-city\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n      <!-- Guarantor State -->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"guarantor-state\">Estado:<\/label>\r\n              <span><input name=\"guarantor-state\" id=\"guarantor-state\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n      <!-- Guarantor Zip -->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"guarantor-zipcode\">C\u00f3digo postal:<\/label>\r\n              <span><input name=\"guarantor-zipcode\" id=\"guarantor-zipcode\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n\r\n    <div class=\"clear\"><\/div>\r\n    <h4 class=\"info-spacer\" style=\"margin-bottom: 15px\">\r\n\t\tRepresentante autorizado por el paciente\r\n    <\/h4>\r\n\r\n    <p class=\"reg-text\"> <strong>Por favor marque S\u00cd o NO para indicar si podemos revelar informaci\u00f3n protegida de salud, incluso informes, im\u00e1genes o informaci\u00f3n financierao del seguro a los representantes autorizados mencionados.<\/span> <\/p>\r\n    <div class=\"clear\"><\/div>\r\n\r\n    <!-- Name-->\r\n    <div class=\"form-group field field-text col col-3\/8\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"name\">Nombre:<\/label>\r\n       <span><input name=\"name\" id=\"name\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- Relationship -->\r\n    <div class=\"form-group field field-text col col-2\/8\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"relationship\">Relaci\u00f3n:<\/label>\r\n       <span><input name=\"relationship\" id=\"relationship\" required=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- contact number -->\r\n    <div class=\"form-group field field-text col col-2\/8\">\r\n      <div class=\"input-cont\">\r\n       <label class=\"control-label\" for=\"ctc-phone\">Tel\u00e9fono#<span>(xxx-xxx-xxxx)<\/span>:<\/label>\r\n       <span><input name=\"ctc-phone\" id=\"ctc-phone\" required=\"\" data-name=\"contact number\" class=\"form-control val-phone\" value=\"\" type=\"tel\"><\/span>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <!-- share records -->\r\n    <div class=\"form-group field field-text col col-1\/8\">\r\n      <div class=\"input-cont\">\r\n        <div class=\"radio-cont\">\r\n         \r\n         <input type=\"radio\" id=\"share-yes\" required=\"\" name=\"share\" value=\"yes\"> <label class=\"radio-label\" for=\"share-yes\">S\u00cd<\/label>\r\n         <input type=\"radio\" id=\"share-no\" name=\"share\" value=\"no\"> <label class=\"radio-label\" for=\"share-no\">NO<\/label><br>\r\n       <\/div>\r\n      <\/div>\r\n    <\/div>\r\n\r\n    <div class=\"clear\"><\/div>\r\n\r\n    <h4 class=\"info-spacer\">\r\n\t\tNotificaci\u00f3n sobre la ley de protecci\u00f3n al consumidor &amp; en llamadas telef\u00f3nicas\r\n      <span class=\"flt-right\"> <i class=\"fa fa-arrow-right\"><\/i> INITIALES: _______________ <\/span>\r\n    <\/h4>\r\n\r\n    <p class=\"disc-txt\">Para prop\u00f3sitos relacionados con mi cuenta o para cobros de cualquier monto que yo adeude, SimonMed o sus agentes pueden comunicarse conmigo por tel\u00e9fono a cualquier n\u00famero telef\u00f3nico asociado con mi cuenta, lo cual incluye, sin limitaci\u00f3n alguna, los tel\u00e9fonos inal\u00e1mbricos o celulares cuyas llamadas pueden ocasionar cargos. Ustedes tambi\u00e9n pueden comunicarse conmigo utilizando mensajes de voz pregrabada o artificial y\/o a trav\u00e9s del uso de dispositivos autom\u00e1ticos de llamada.<\/p>\r\n\r\n    <div class=\"clear\"><\/div>\r\n\r\n    <h4 class=\"info-spacer\">\r\n\t\tPol\u00edtica de pago\r\n    <\/h4>\r\n\r\n\t<p class=\"disc-txt\">\r\n\t\tPor favor revise nuestra pol\u00edtica de pago y si tiene preguntas podemos discutirlas antes de su examen.\r\n\t\t<strong class=\"underlined\">Seguro:<\/strong> Participamos en la mayor\u00eda de los planes de seguro, incluso\r\n\t\tMedicare. Si usted no tiene seguro o no est\u00e1 cubierto por un plan de seguro aceptado por nosotros, el pago\r\n\t\tcompleto debe hacerse en el momento en que los servicios sean proporcionados, a no ser que se haya hecho y\r\n\t\taceptado anticipadamente otro tipo de arreglo. <strong class=\"underlined\">Prueba de seguro\/Formularios de\r\n\t\t\treferencia:<\/strong> Podemos requerir que usted nos proporcione una copia de su licencia de conducir y\r\n\t\ttarjeta v\u00e1lida de seguro para comprobar que tiene seguro. Si no nos proporciona la informaci\u00f3n correcta,\r\n\t\tusted ser\u00e1 responsable por el pago. Si no tiene su tarjeta de seguro, usted ser\u00e1 responsable por el pago en\r\n\t\tel momento del servicio. Una vez que obtengamos informaci\u00f3n de su seguro, cobraremos a la aseguradora y le\r\n\t\treembolsaremos cualquier pago en exceso cuando el reclamo sea pagado por su plan de seguro. Si su seguro\r\n\t\tcambia, por favor notif\u00edquenos inmediatamente para evitar problemas con el pago de su reclamo. <strong class=\"underlined\">Copagos, deducibles y coaseguro:<\/strong> Usted acepta pagar todos los copagos,\r\n\t\tdeducibles y coaseguros, de acuerdo a lo requerido por su plan de seguro, en el momento en que se efect\u00faen\r\n\t\tsus ex\u00e1menes. <strong class=\"underlined\">Servicios no cubiertos:<\/strong> En algunos casos, los servicios\r\n\t\tque usted recibe pueden no estar cubiertos o no ser considerados m\u00e9dicamente necesarios por Medicare u otros\r\n\t\tplanes de seguro. En tales casos, se le requerir\u00e1 pagar estos servicios por completo en el momento de su\r\n\t\texamen. A fin de poder proporcionar servicios a los pacientes de Medicare, es posible que se les pida\r\n\t\tcompletar separadamente un formulario de aviso de anticipo a beneficiario. <strong class=\"underlined\">Cesi\u00f3n:<\/strong>\r\n\t\tAl firmar este formulario, usted acepta ceder todos los beneficios del seguro por los servicios prestados a\r\n\t\tSimonMed Imaging y autoriza a SimonMed Imaging a someter un reclamo a Medicare o su plan de seguro. Nosotros\r\n\t\tpresentaremos sus reclamos a su plan de seguro y le proporcionaremos asistencia razonable para lograr que el\r\n\t\tplan de seguro pague los reclamos. <strong class=\"underlined\">Cobros:<\/strong> Una vez que una cuenta ha\r\n\t\tsido transferida a cobranzas, todos los servicios futuros deber\u00e1n ser pagados por completo en el momento del\r\n\t\tservicio. Se cobrar\u00e1 una multa de $25.00 por cualquier cheque rechazado. Las pol\u00edticas para pagos de los\r\n\t\tpacientes pueden no ser aplicables en ciertos casos, los cuales incluyen, aunque sin limitarse a los mismos,\r\n\t\tlos casos de compensaci\u00f3n por accidentes de trabajo\r\n\t<\/p>\r\n\r\n\t<h4 class=\"info-spacer\">\r\n\t\tAvisos de pr\u00e1cticas de privacidad y derechos del paciente\r\n\t<\/h4>\r\n\r\n    <p class=\"disc-txt\">\r\n\t\tAl firmar este formulario, acuso recibo de los avisos de Pr\u00e1cticas de Privacidad y Derechos del Paciente\r\n\t\tproporcionados por el proveedor y confirmo que se me ha dado la oportunidad de leerlos.\r\n\t<\/p>\r\n\r\n    <h4 class=\"info-spacer\">\r\n\t\tAutorizaci\u00f3n para revelar o proporcionar informaci\u00f3n\r\n\t<\/h4>\r\n\r\n\t<p class=\"disc-txt\">\r\n\t\tSimonMed Imaging puede revelar total o parcialmente el r\u00e9cord m\u00e9dico y\/o financiero del paciente a su plan\r\n\t\tde seguro para determinar la elegibilidad a los beneficios, a sus m\u00e9dicos y a otros proveedores de atenci\u00f3n\r\n\t\tde salud responsables por la atenci\u00f3n del paciente. Nosotros podemos solicitar informaci\u00f3n de salud\r\n\t\trelacionada con los estudios efectuados por SimonMed. Esta informaci\u00f3n puede incluir im\u00e1genes de ex\u00e1menes\r\n\t\tprevios, historial, s\u00edntomas, resultados de laboratorio, informes de patolog\u00eda, etc. Entiendo que la\r\n\t\tautorizaci\u00f3n de representante del paciente indicada arriba se mantendr\u00e1 vigente por un a\u00f1o (o hasta la fecha\r\n\t\tde mi pr\u00f3xima cita), cualquiera de las dos fechas que ocurra primero. SimonMed Imaging puede cobrar una\r\n\t\ttarifa hasta un m\u00e1ximo de $25.00 por cada juego de im\u00e1genes solicitado.\r\n\t<\/p>\r\n\r\n\t<h4 class=\"info-spacer\">\r\n\t\tConsentimiento general al tratamiento y derecho a rechazarlo\r\n\t<\/h4>\r\n\r\n\t<p class=\"disc-txt\">\r\n\t\t<strong class=\"underlined\">Consentimiento general al tratamiento: <\/strong> Al firmar a continuaci\u00f3n, yo\r\n\t\tpersonalmente (o por medio de mi representante autorizado) autorizo a SimonMed Imaging y a su personal a\r\n\t\tefectuar cualquier examen, prueba y procedimiento diagn\u00f3stico y a proporcionar cualquier medicamento o\r\n\t\ttratamiento para evaluar y mantener eficazmente mi salud y para evaluar, diagnosticar y tratar mi enfermedad\r\n\t\to lesiones. Entiendo que es responsabilidad de mi proveedor o proveedores de atenci\u00f3n de salud explicarme\r\n\t\tlas razones por las que se requiere cualquier examen, prueba o procedimiento diagn\u00f3stico, las opciones\r\n\t\tdisponibles de tratamiento y los riesgos y beneficios comunes asociados con estas opciones, as\u00ed como los\r\n\t\tcursos alternativos de tratamiento. <strong class=\"underlined\">Derecho a rechazar el tratamiento:<\/strong>\r\n\t\tAl otorgar mi consentimiento general al tratamiento, entiendo que retengo el derecho de rechazar cualquier\r\n\t\texamen, prueba, procedimiento, tratamiento o medicamento en particular que haya sido recomendado o\r\n\t\tconsiderado necesario por mi m\u00e9dico. Tambi\u00e9n entiendo que la pr\u00e1ctica de la medicina no es una ciencia\r\n\t\texacta y que no se me ha dado ninguna garant\u00eda con respecto a los resultados de mi evaluaci\u00f3n y\/o\r\n\t\ttratamiento.\r\n\t<\/p>\r\n\r\n\t<p class=\"itl-txt\">\r\n\t\tAl firmar abajo, declaro que entiendo y acepto las pol\u00edticas y declaraciones anteriores.\r\n\t<\/p>\r\n\r\n    <div class=\" sign-area\">\r\n        <!-- Patient Signature -->\r\n        <div class=\"form-group field field-text col col-2\/3\">\r\n          <div class=\"input-cont\">\r\n\t\t\t<label class=\"control-label\" for=\"patient-sign\">Firma del paciente:<\/label>\r\n           <span><input name=\"patient-sign\" id=\"patient-sign\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n        <\/div>\r\n\r\n        <!-- Sign Date-->\r\n        <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n           <label class=\"control-label\" for=\"sign-date\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n           <span><input name=\"sign-date\" id=\"sign-date\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n          <\/div>\r\n        <\/div>\r\n    <\/div>\r\n    <div class=\" sign-area\">\r\n      <!-- Patient Signature -->\r\n      <div class=\"form-group field field-text col col-2\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"patient-sign-2\">Firma del paciente:<\/label>\r\n              <span><input name=\"patient-sign-2\" id=\"patient-sign-2\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n      <!-- Sign Date-->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"sign-date-2\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n              <span><input name=\"sign-date-2\" id=\"sign-date-2\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n    <\/div>\r\n    <div class=\" sign-area\">\r\n      <!-- Patient Signature -->\r\n      <div class=\"form-group field field-text col col-2\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"patient-sign-3\">Firma del paciente:<\/label>\r\n              <span><input name=\"patient-sign-3\" id=\"patient-sign-3\" disabled=\"\" class=\"form-control\" value=\"\" type=\"text\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n\r\n      <!-- Sign Date-->\r\n      <div class=\"form-group field field-text col col-1\/3\">\r\n          <div class=\"input-cont\">\r\n              <label class=\"control-label\" for=\"sign-date-3\">Date <span>(mm\/dd\/yyyy)<\/span>:<\/label>\r\n              <span><input name=\"sign-date-3\" id=\"sign-date-3\" required=\"\" class=\"form-control date hasDatepicker\" value=\"\" type=\"date\"><\/span>\r\n          <\/div>\r\n      <\/div>\r\n    <\/div>\r\n\r\n\r\n      <div class=\"print-footer\">\r\n        <div class=\"col col-1\/2 txt-left\">PT.CK.001<\/div>\r\n      <div class=\"col col-1\/2 txt-right\">001ACTUALIZADO: 7\/19\/2018<\/div>\r\n      <\/div>\r\n    <div class=\"clear\"><\/div>\r\n\r\n  <button class=\"call-to-action print-form elementor-button col-full\" type=\"submit\">Imprimir p\u00e1gina<\/button>\r\n\r\n\r\n  <\/form>\r\n\r\n<\/div>\r\n\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-18a29de1 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"18a29de1\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-54561b65\" data-id=\"54561b65\" data-element_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-13f7435b elementor-widget elementor-widget-image\" data-id=\"13f7435b\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-image{text-align:center}.elementor-widget-image a{display:inline-block}.elementor-widget-image a img[src$=\".svg\"]{width:48px}.elementor-widget-image img{vertical-align:middle;display:inline-block}<\/style>\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"100\" height=\"52\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\" class=\"attachment-large size-large wp-image-443\" alt=\"American College of Radiology\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-3c6e1764 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3c6e1764\" data-element_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-inner-column elementor-element elementor-element-33bbc9a2\" data-id=\"33bbc9a2\" data-element_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-6ee6f0b6 elementor-widget elementor-widget-heading\" data-id=\"6ee6f0b6\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Why Choose Us<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7672c18d elementor-widget elementor-widget-text-editor\" data-id=\"7672c18d\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<p>SimonMed Imaging and its affiliates have been serving the community for over 30 years. Our mission is to provide best-in class affordable care through the use of advanced technology. We have patient-focused staff and highly trained medical professionals.<br \/><br \/>SimonMed has over 160 convenient locations across 11 states and provides late night and weekend appointments to accommodate patients.<\/p>\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-inner-section elementor-element elementor-element-3a35fe7d img-choose-wrp elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3a35fe7d\" data-element_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-inner-column elementor-element elementor-element-cd65c0f\" data-id=\"cd65c0f\" data-element_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-3da0f4ef elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"3da0f4ef\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"86\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/radsite2.png\" class=\"attachment-medium size-medium wp-image-409\" alt=\"RadSite Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-14dcfa3 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"14dcfa3\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"88\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-top-doctor.png\" class=\"attachment-medium size-medium wp-image-406\" alt=\"Top Doctor Icon\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4004a691 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"4004a691\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"78\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-interelated.png\" class=\"attachment-medium size-medium wp-image-407\" alt=\"Intelerad Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4f77ca62 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"4f77ca62\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-sectra.png\" class=\"attachment-medium size-medium wp-image-408\" alt=\"Sectra Logo\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5be59c38 elementor-widget__width-auto elementor-widget elementor-widget-image\" data-id=\"5be59c38\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"81\" height=\"80\" src=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-radsite.png\" class=\"attachment-medium size-medium wp-image-405\" alt=\"RadSite Icon\" \/>\t\t\t\t\t\t\t\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\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient Information Form &#8211; Spanish descargar pdf Hora de llegada: MRN: Informaci\u00f3n del paciente \u2013 POR FAVOR EN LETRA DE MOLDE Nombre del paciente (apellido, primer nombre): Masculino Femenino Fecha de nacimiento: N\u00famero de seguro social (xxx-xx-xxxx) (opcional): Direcci\u00f3n de correo: Ciudad: Estado: &#8212;ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY C\u00f3digo postal: Tel\u00e9fono de casa# (xxx-xxx-xxxx): Celular# (xxx-xxx-xxxx): Correo electr\u00f3nico: Persona [&hellip;]<\/p>\n","protected":false},"author":10,"featured_media":0,"parent":46,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Information Form - Spanish - SimonMed Website<\/title>\n<meta name=\"description\" content=\"Patient Information Form - Spanish\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Information Form - Spanish - SimonMed Website\" \/>\n<meta property=\"og:description\" content=\"Patient Information Form - Spanish\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/\" \/>\n<meta property=\"og:site_name\" content=\"SimonMed Website\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/SimonMed\/\" \/>\n<meta property=\"article:modified_time\" content=\"2022-09-30T10:32:27+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"7 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/\",\"url\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/\",\"name\":\"Patient Information Form - Spanish - SimonMed Website\",\"isPartOf\":{\"@id\":\"https:\/\/www.simonmed.com\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"datePublished\":\"2022-01-24T13:32:09+00:00\",\"dateModified\":\"2022-09-30T10:32:27+00:00\",\"description\":\"Patient Information Form - Spanish\",\"breadcrumb\":{\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/\"]}]},{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/#primaryimage\",\"url\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"contentUrl\":\"https:\/\/www.simonmed.com\/wp-content\/uploads\/2022\/01\/icon-why-choose-us.png\",\"width\":100,\"height\":52,\"caption\":\"American College of Radiology\"},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.simonmed.com\/patient-info\/patient-information-form-spanish\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/www.simonmed.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Patient Info\",\"item\":\"https:\/\/www.simonmed.com\/patient-info\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Patient Information Form &#8211; 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