{"id":715,"date":"2025-08-07T02:52:55","date_gmt":"2025-08-07T02:52:55","guid":{"rendered":"https:\/\/hurtadoplasticsurgery.com\/?page_id=715"},"modified":"2025-08-07T08:35:48","modified_gmt":"2025-08-07T08:35:48","slug":"virtual-consultation","status":"publish","type":"page","link":"https:\/\/hurtadoplasticsurgery.com\/es\/virtual-consultation\/","title":{"rendered":"Consulta virtual"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_heading title=&#8221;Virtual Consultation&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; title_level=&#8221;h3&#8243; title_font=&#8221;&#8211;et_global_body_font|&#8211;et_global_body_font_weight|||||||&#8221; title_text_align=&#8221;center&#8221; title_text_color=&#8221;#250C04&#8243; title_font_size=&#8221;20px&#8221; custom_margin=&#8221;||8px||false|false&#8221; title_text_align_tablet=&#8221;center&#8221; title_text_align_phone=&#8221;center&#8221; title_text_align_last_edited=&#8221;on|desktop&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_heading][et_pb_heading title=&#8221;A better you awaits&#8221; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; title_level=&#8221;h2&#8243; title_text_align=&#8221;center&#8221; title_text_color=&#8221;#250C04&#8243; title_font_size=&#8221;48px&#8221; custom_margin=&#8221;||32px||false|false&#8221; global_colors_info=&#8221;{}&#8221;][\/et_pb_heading][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; text_text_color=&#8221;#250C04&#8243; custom_margin=&#8221;||20px||false|false&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p><span>In our Plastic Surgery Clinic, we are pleased to offer you the convenience of virtual consultations to obtain an accurate quote for your preferred procedure. Our online process is simple and efficient, requiring only a few minutes of your time.<\/span><\/p>\n<p><span>We invite you to complete our virtual form, where you can provide your personal information along with a brief description of your desired procedure. Once we receive your form, our team of highly experienced surgeons will carefully review your request and provide you with a detailed quote free of charge.<\/span><\/p>\n<p><b>We value the confidentiality of your information and want to assure you that all data provided in the form will be treated with the utmost discretion and used exclusively for the purpose of providing you with the best possible care.<br \/><\/b><br \/><span>At Hurtado Vidal Plastic Surgery, we are committed to making your consultation experience professional, reliable, and tailored to your individual needs. We look forward to being part of your journey to plastic surgery with ease and convenience.<\/span><\/p>\n<p>[\/et_pb_text][et_pb_code _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_css_free_form=&#8221;selector .forminator-button {||  background: transparent !important;||  border: 1px #916F52 solid !important;||\ttext-transform: uppercase;||\ttransition: color 300ms !important;||  padding: 12px 24px !important;||  box-shadow: none !important;||}||||selector .forminator-button:hover, selector .forminator-button:focus {||  background: #916F52 !important;||\ttext-transform: uppercase;||}||||selector label.forminator-label {||  font-weight: 300 !important;||  font-size: 14px !important;||}||||selector .forminator-input {||  border: 1px #916F52 solid !important;||  padding: 16px !important;||  color: rgba(145,111,82,0.58) !important;||}||||selector span.selection .select2-selection {||  background: transparent !important;||\tborder: 1px #916F52 solid !important;||}||||selector span.selection .select2-selection .select2-selection__rendered {||\tpadding: 16px !important;||  font-family: &#8216;Karla&#8217; !important;||  font-weight: 300 !important;||  color: rgba(145,111,82,0.58) !important;||}||||selector textarea.forminator-textarea {||  resize: none !important;||  border: 1px #916F52 solid !important;||}||||selector .forminator-icon-calendar::before {||  content: &#8221; !important;||}&#8221; global_colors_info=&#8221;{}&#8221;]<div class=\"forminator-ui forminator-custom-form forminator-custom-form-718 forminator-design--flat  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-718\" data-uid=\"6a937b448869e\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-718\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-718 forminator-design--flat  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"718\"\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"flat\" data-grid=\"open\" style=\"display: none;\"\n\t\t\t\tdata-uid=\"6a937b448869e\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-0\"\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-0-label\"\n\t\t\t\tdata-step=\"0\"\n\t\t\t\tdata-label=\"Finish\"\n\t\t\t\tdata-actual-label=\"1\"\n\t\t\t\tdata-name=\"page-break-1\"\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_6a937b448869e\" id=\"forminator-field-name-1_6a937b448869e-label\" class=\"forminator-label\">Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"\" id=\"forminator-field-name-1_6a937b448869e\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_6a937b448869e\" id=\"forminator-field-name-2_6a937b448869e-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_6a937b448869e\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" autocomplete=\"name\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a937b448869e\" id=\"forminator-field-text-1_6a937b448869e-label\" class=\"forminator-label\">Age <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-718__field--select-1_6a937b448869e\" id=\"forminator-form-718__field--select-1_6a937b448869e-label\" class=\"forminator-label\">Gender <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-718__field--select-1_6a937b448869e\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-1\" data-default-value=\"two\" data-hidden-behavior=\"zero\" data-placeholder=\"Please select an option\" data-search=\"false\" data-search-placeholder=\"Please select an option\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-718__field--select-1_6a937b448869e-label\"><option value=\"\"  >Please select an option<\/option><option value=\"two\" selected=\"selected\" data-calculation=\"0\">Female<\/option><option value=\"one\"  data-calculation=\"0\">Male<\/option><\/select><\/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-718__field--select-2_6a937b448869e\" id=\"forminator-form-718__field--select-2_6a937b448869e-label\" class=\"forminator-label\">Preferred language<\/label><select  id=\"forminator-form-718__field--select-2_6a937b448869e\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"\" data-search=\"false\" data-search-placeholder=\"\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-718__field--select-2_6a937b448869e-label\"><option value=\"one\"  data-calculation=\"0\">English<\/option><option value=\"two\"  data-calculation=\"0\">Spanish<\/option><\/select><\/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-718__field--select-3_6a937b448869e\" id=\"forminator-form-718__field--select-3_6a937b448869e-label\" class=\"forminator-label\">How did you find out about Dr. Hurtado Vidal? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-718__field--select-3_6a937b448869e\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"How did you find out about Dr. Hurtado Vidal?\" data-search=\"false\" data-search-placeholder=\"How did you find out about Dr. Hurtado Vidal?\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-718__field--select-3_6a937b448869e-label\"><option value=\"\"  >How did you find out about Dr. Hurtado Vidal?<\/option><option value=\"one\"  data-calculation=\"0\">Google<\/option><option value=\"two\"  data-calculation=\"0\">Instagram<\/option><option value=\"Facebook\"  data-calculation=\"0\">Facebook<\/option><option value=\"Tiktok\"  data-calculation=\"0\">Tiktok<\/option><option value=\"Referred-from-another-patient\"  data-calculation=\"0\">Referred from another patient<\/option><option value=\"I-am-a-returning-patient\"  data-calculation=\"0\">I am a returning patient<\/option><option value=\"Other\"  data-calculation=\"0\">Other<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-1\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-1-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"1\"\n\t\t\t\tdata-label=\"1\"\n\t\t\t\tdata-actual-label=\"2\"\n\t\t\t\tdata-name=\"page-break-2\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a937b448869e\" id=\"forminator-field-email-1_6a937b448869e-label\" class=\"forminator-label\">Email <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a937b448869e\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a937b448869e\" id=\"forminator-field-phone-1_6a937b448869e-label\" class=\"forminator-label\">Phone Number <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a937b448869e\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a937b448869e\" id=\"forminator-field-phone-2_6a937b448869e-label\" class=\"forminator-label\">Additional Phone Number<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a937b448869e\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a937b448869e\" id=\"forminator-field-text-2_6a937b448869e-label\" class=\"forminator-label\">City and state of residence <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-2\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-2-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"2\"\n\t\t\t\tdata-label=\"2\"\n\t\t\t\tdata-actual-label=\"3\"\n\t\t\t\tdata-name=\"page-break-3\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a937b448869e\" id=\"forminator-field-text-3_6a937b448869e-label\" class=\"forminator-label\">Weight (lbs. or kg.) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a937b448869e\" id=\"forminator-field-text-4_6a937b448869e-label\" class=\"forminator-label\">Height (ft. or mts.) <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a937b448869e\" id=\"forminator-field-text-5_6a937b448869e-label\" class=\"forminator-label\">Body mass<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a937b448869e\" id=\"forminator-field-text-6_6a937b448869e-label\" class=\"forminator-label\">Blood Group (Blood Type)<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a937b448869e\" id=\"forminator-field-text-7_6a937b448869e-label\" class=\"forminator-label\">Maximum weight you have ever had <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-718__field--select-4_6a937b448869e\" id=\"forminator-form-718__field--select-4_6a937b448869e-label\" class=\"forminator-label\">Select <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-718__field--select-4_6a937b448869e\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-4\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Have you gained weight lately?\" data-search=\"false\" data-search-placeholder=\"Have you gained weight lately?\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-718__field--select-4_6a937b448869e-label\"><option value=\"\"  >Have you gained weight lately?<\/option><option value=\"one\"  data-calculation=\"0\">Yes<\/option><option value=\"two\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a937b448869e\" id=\"forminator-field-text-8_6a937b448869e-label\" class=\"forminator-label\">If true, approximately: How much have you gained in the last 3 months?<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a937b448869e\" id=\"forminator-field-textarea-1_6a937b448869e-label\" class=\"forminator-label\">Do you have any physical impediment? If so, please mention it<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a937b448869e\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-3\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-3-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"3\"\n\t\t\t\tdata-label=\"3\"\n\t\t\t\tdata-actual-label=\"4\"\n\t\t\t\tdata-name=\"page-break-4\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Medication and Supplements<\/label><div role=\"listitem\" class=\"Qr7Oae pQK2A\">\n<div role=\"heading\" class=\"KkG9vf mBzBBe\">\n<div class=\"SajZGc RVEQke hN5qnf\">\n<div class=\"aG9Vid vVO4xd  M7eMe\">We strive to provide quality care and services to our patients. During virtual consultations, we request that patients provide us with all relevant medical and supplementary information. This may include any medical history, current medical treatments, medications being used, allergies, and general health information. Additionally, we request any supplementary information that may be relevant to the consultation. This way, we can ensure that our patients receive the best possible care.<br><br><b><i>*(including hormonal contraceptives and hormone therapies)<\/i><\/b><\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a937b448869e\" id=\"forminator-field-text-9_6a937b448869e-label\" class=\"forminator-label\">Relevant medical information (medications in use, brand, dose and reason for use) If this is not the case, you can leave it blank.<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-4\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-4-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"4\"\n\t\t\t\tdata-label=\"4\"\n\t\t\t\tdata-actual-label=\"5\"\n\t\t\t\tdata-name=\"page-break-5\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><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-1-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a937b448869e-label\" class=\"forminator-label\">Illnesses you have suffered or are currently experiencing.<\/span><span id=\"forminator-field-checkbox-1-6a937b448869e-description\" class=\"forminator-description\">* Please select the boxes that apply.<\/span><label id=\"forminator-field-checkbox-1-1-6a937b448869e-label\" for=\"forminator-field-checkbox-1-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Cardiovascular disease\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cardiovascular-disease\" id=\"forminator-field-checkbox-1-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cardiovascular disease<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a937b448869e-label\" for=\"forminator-field-checkbox-1-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Diabetes type 1\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Diabetes-type-1\" id=\"forminator-field-checkbox-1-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diabetes type 1<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a937b448869e-label\" for=\"forminator-field-checkbox-1-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Type 2 diabetes\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Type-2-diabetes\" id=\"forminator-field-checkbox-1-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Type 2 diabetes<\/span><\/label><label id=\"forminator-field-checkbox-1-4-6a937b448869e-label\" for=\"forminator-field-checkbox-1-4-6a937b448869e\" class=\"forminator-checkbox\" title=\"Asthma\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Asthma\" id=\"forminator-field-checkbox-1-4-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-4-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Asthma<\/span><\/label><label id=\"forminator-field-checkbox-1-5-6a937b448869e-label\" for=\"forminator-field-checkbox-1-5-6a937b448869e\" class=\"forminator-checkbox\" title=\"Cholesterol\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cholesterol\" id=\"forminator-field-checkbox-1-5-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-5-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cholesterol<\/span><\/label><label id=\"forminator-field-checkbox-1-6-6a937b448869e-label\" for=\"forminator-field-checkbox-1-6-6a937b448869e\" class=\"forminator-checkbox\" title=\"Thyroid\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Thyroid\" id=\"forminator-field-checkbox-1-6-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-6-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thyroid<\/span><\/label><label id=\"forminator-field-checkbox-1-7-6a937b448869e-label\" for=\"forminator-field-checkbox-1-7-6a937b448869e\" class=\"forminator-checkbox\" title=\"Arthritis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Arthritis\" id=\"forminator-field-checkbox-1-7-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-7-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Arthritis<\/span><\/label><label id=\"forminator-field-checkbox-1-8-6a937b448869e-label\" for=\"forminator-field-checkbox-1-8-6a937b448869e\" class=\"forminator-checkbox\" title=\"Heart attacks\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Heart-attacks\" id=\"forminator-field-checkbox-1-8-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-8-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Heart attacks<\/span><\/label><label id=\"forminator-field-checkbox-1-9-6a937b448869e-label\" for=\"forminator-field-checkbox-1-9-6a937b448869e\" class=\"forminator-checkbox\" title=\"Anemia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Anemia\" id=\"forminator-field-checkbox-1-9-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-9-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anemia<\/span><\/label><label id=\"forminator-field-checkbox-1-10-6a937b448869e-label\" for=\"forminator-field-checkbox-1-10-6a937b448869e\" class=\"forminator-checkbox\" title=\"Kidney Diseases\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Kidney-Diseases\" id=\"forminator-field-checkbox-1-10-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-10-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Kidney Diseases<\/span><\/label><label id=\"forminator-field-checkbox-1-11-6a937b448869e-label\" for=\"forminator-field-checkbox-1-11-6a937b448869e\" class=\"forminator-checkbox\" title=\"Osteoporosis or Osteopenia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Osteoporosis-or-Osteopenia\" id=\"forminator-field-checkbox-1-11-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-11-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Osteoporosis or Osteopenia<\/span><\/label><label id=\"forminator-field-checkbox-1-12-6a937b448869e-label\" for=\"forminator-field-checkbox-1-12-6a937b448869e\" class=\"forminator-checkbox\" title=\"Obesity\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Obesity\" id=\"forminator-field-checkbox-1-12-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-12-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Obesity<\/span><\/label><label id=\"forminator-field-checkbox-1-13-6a937b448869e-label\" for=\"forminator-field-checkbox-1-13-6a937b448869e\" class=\"forminator-checkbox\" title=\"Lupus\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Lupus\" id=\"forminator-field-checkbox-1-13-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-13-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lupus<\/span><\/label><label id=\"forminator-field-checkbox-1-14-6a937b448869e-label\" for=\"forminator-field-checkbox-1-14-6a937b448869e\" class=\"forminator-checkbox\" title=\"Polycystic ovary syndrome\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Polycystic-ovary-syndrome\" id=\"forminator-field-checkbox-1-14-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-14-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Polycystic ovary syndrome<\/span><\/label><label id=\"forminator-field-checkbox-1-15-6a937b448869e-label\" for=\"forminator-field-checkbox-1-15-6a937b448869e\" class=\"forminator-checkbox\" title=\"Bleeding or Clotting Problems\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Bleeding-or-Clotting-Problems\" id=\"forminator-field-checkbox-1-15-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-15-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bleeding or Clotting Problems<\/span><\/label><label id=\"forminator-field-checkbox-1-16-6a937b448869e-label\" for=\"forminator-field-checkbox-1-16-6a937b448869e\" class=\"forminator-checkbox\" title=\"Problems with Anesthesia\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Problems-with-Anesthesia\" id=\"forminator-field-checkbox-1-16-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-16-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Problems with Anesthesia<\/span><\/label><label id=\"forminator-field-checkbox-1-17-6a937b448869e-label\" for=\"forminator-field-checkbox-1-17-6a937b448869e\" class=\"forminator-checkbox\" title=\"Allergies\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"allergies\" id=\"forminator-field-checkbox-1-17-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-17-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Allergies<\/span><\/label><label id=\"forminator-field-checkbox-1-18-6a937b448869e-label\" for=\"forminator-field-checkbox-1-18-6a937b448869e\" class=\"forminator-checkbox\" title=\"Blood clots\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"blood-clots\" id=\"forminator-field-checkbox-1-18-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-18-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Blood clots<\/span><\/label><label id=\"forminator-field-checkbox-1-19-6a937b448869e-label\" for=\"forminator-field-checkbox-1-19-6a937b448869e\" class=\"forminator-checkbox\" title=\"High pressure\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"High-pressure\" id=\"forminator-field-checkbox-1-19-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-19-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">High pressure<\/span><\/label><label id=\"forminator-field-checkbox-1-20-6a937b448869e-label\" for=\"forminator-field-checkbox-1-20-6a937b448869e\" class=\"forminator-checkbox\" title=\"Multiple sclerosis\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Multiple-sclerosis\" id=\"forminator-field-checkbox-1-20-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-20-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Multiple sclerosis<\/span><\/label><label id=\"forminator-field-checkbox-1-21-6a937b448869e-label\" for=\"forminator-field-checkbox-1-21-6a937b448869e\" class=\"forminator-checkbox\" title=\"Diagnosed Depression\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Diagnosed-Depression\" id=\"forminator-field-checkbox-1-21-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-21-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Diagnosed Depression<\/span><\/label><label id=\"forminator-field-checkbox-1-22-6a937b448869e-label\" for=\"forminator-field-checkbox-1-22-6a937b448869e\" class=\"forminator-checkbox\" title=\"Cancer\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Cancer\" id=\"forminator-field-checkbox-1-22-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-1-22-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\" aria-describedby=\"forminator-field-checkbox-1-6a937b448869e-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Cancer<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a937b448869e\" id=\"forminator-field-textarea-2_6a937b448869e-label\" class=\"forminator-label\">Other Personal Conditions<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a937b448869e\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_6a937b448869e\" id=\"forminator-field-text-10_6a937b448869e-label\" class=\"forminator-label\">Do you have allergies? (If so, please mention which ones)<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_6a937b448869e\" id=\"forminator-field-text-11_6a937b448869e-label\" class=\"forminator-label\">Have you had any Bariatric Surgery, Gastric Sleeve, Gastric Bypass, Mini Gastric Bypass? If so, mention them and the their respective dates<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_6a937b448869e\" id=\"forminator-field-text-12_6a937b448869e-label\" class=\"forminator-label\">Have you had Injections for the Buttocks? If so, mention the date of the last<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_6a937b448869e\" id=\"forminator-field-text-13_6a937b448869e-label\" class=\"forminator-label\">Have you had any other surgery in the past? Please mention which ones with their approximate dates (Month and Year)<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_6a937b448869e\" id=\"forminator-field-text-14_6a937b448869e-label\" class=\"forminator-label\">Surgical complications that you have had in your past surgeries?<\/label><span id=\"forminator-field-text-14_6a937b448869e-description\" class=\"forminator-description\">(Please describe)<\/span><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-14_6a937b448869e-description\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-5\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-5-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"5\"\n\t\t\t\tdata-label=\"5\"\n\t\t\t\tdata-actual-label=\"6\"\n\t\t\t\tdata-name=\"page-break-6\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><label class=\"forminator-label\">Gyneco-ostetric history<\/label><p><b><u>*If you are a man, please skip this section.<\/u><\/b><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a937b448869e\" id=\"forminator-field-date-1-picker_6a937b448869e-label\" class=\"forminator-label\">Have you had a pregnancy? If so, mention the date of your last pregnancy<\/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=\"Choose Date\" id=\"forminator-field-date-1-picker_6a937b448869e\" class=\"forminator-input forminator-datepicker\" data-required=\"\" 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=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_6a937b448869e\" id=\"forminator-field-text-15_6a937b448869e-label\" class=\"forminator-label\">How many deliveries?<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_6a937b448869e\" id=\"forminator-field-text-16_6a937b448869e-label\" class=\"forminator-label\">How many C-sections?<\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_6a937b448869e\" id=\"forminator-field-text-17_6a937b448869e-label\" class=\"forminator-label\">How many abortions?<\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_6a937b448869e\" id=\"forminator-field-text-18_6a937b448869e-label\" class=\"forminator-label\">Menarche<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_6a937b448869e\" id=\"forminator-field-text-19_6a937b448869e-label\" class=\"forminator-label\">Menstrual cycle<\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_6a937b448869e\" id=\"forminator-field-text-20_6a937b448869e-label\" class=\"forminator-label\">Contraceptive Method (including hormonal contraceptives and hormonal therapies)<\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-6\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-6-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"6\"\n\t\t\t\tdata-label=\"6\"\n\t\t\t\tdata-actual-label=\"7\"\n\t\t\t\tdata-name=\"page-break-7\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><label class=\"forminator-label\">Personal Habits<\/label><p><b>Please make sure you do not omit any drugs or substances.<\/b> Rest assured that you will not be judged for it and having this information will allow our surgical team to act correctly in the event of a complication within the operating room.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-718__field--select-5_6a937b448869e\" id=\"forminator-form-718__field--select-5_6a937b448869e-label\" class=\"forminator-label\">Do you smoke? <span class=\"forminator-required\">*<\/span><\/label><select  id=\"forminator-form-718__field--select-5_6a937b448869e\" class=\"forminator-select--field forminator-select2 forminator-select2-multiple\" data-required=\"1\" name=\"select-5\" data-default-value=\"\" data-hidden-behavior=\"zero\" data-placeholder=\"Do you smoke?\" data-search=\"false\" data-search-placeholder=\"Do you smoke?\" data-checkbox=\"false\" data-allow-clear=\"false\" aria-labelledby=\"forminator-form-718__field--select-5_6a937b448869e-label\"><option value=\"\"  >Do you smoke?<\/option><option value=\"one\"  data-calculation=\"0\">Yes<\/option><option value=\"two\"  data-calculation=\"0\">No<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_6a937b448869e\" id=\"forminator-field-text-21_6a937b448869e-label\" class=\"forminator-label\">Approximately: What is your alcohol consumption per week?<\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_6a937b448869e\" id=\"forminator-field-text-22_6a937b448869e-label\" class=\"forminator-label\">Any other substance for recreational use that you consume? If so, please mention which one<\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-7\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-7-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"7\"\n\t\t\t\tdata-label=\"7\"\n\t\t\t\tdata-actual-label=\"8\"\n\t\t\t\tdata-name=\"page-break-8\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a937b448869e\" id=\"forminator-field-date-2-picker_6a937b448869e-label\" class=\"forminator-label\">Approximate date of interest for your surgery <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-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6a937b448869e\" 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=\"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-2-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a937b448869e-label\" class=\"forminator-label\">Facial Surgery<\/span><label id=\"forminator-field-checkbox-2-1-6a937b448869e-label\" for=\"forminator-field-checkbox-2-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Blepharoplasty\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Blepharoplasty<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a937b448869e-label\" for=\"forminator-field-checkbox-2-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Neck stretch\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Neck stretch<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a937b448869e-label\" for=\"forminator-field-checkbox-2-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Face lift\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Face-lift\" id=\"forminator-field-checkbox-2-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Face lift<\/span><\/label><label id=\"forminator-field-checkbox-2-4-6a937b448869e-label\" for=\"forminator-field-checkbox-2-4-6a937b448869e\" class=\"forminator-checkbox\" title=\"Chin implant\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Chin-implant\" id=\"forminator-field-checkbox-2-4-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-4-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Chin implant<\/span><\/label><label id=\"forminator-field-checkbox-2-5-6a937b448869e-label\" for=\"forminator-field-checkbox-2-5-6a937b448869e\" class=\"forminator-checkbox\" title=\"Ears \/ Optoplasty\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Ears---Optoplasty\" id=\"forminator-field-checkbox-2-5-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-5-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Ears \/ Optoplasty<\/span><\/label><label id=\"forminator-field-checkbox-2-6-6a937b448869e-label\" for=\"forminator-field-checkbox-2-6-6a937b448869e\" class=\"forminator-checkbox\" title=\"Rhinoplasty\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Rhinoplasty\" id=\"forminator-field-checkbox-2-6-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-6-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Rhinoplasty<\/span><\/label><label id=\"forminator-field-checkbox-2-7-6a937b448869e-label\" for=\"forminator-field-checkbox-2-7-6a937b448869e\" class=\"forminator-checkbox\" title=\"Bichectomy\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Bichectomy\" id=\"forminator-field-checkbox-2-7-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-7-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Bichectomy<\/span><\/label><label id=\"forminator-field-checkbox-2-8-6a937b448869e-label\" for=\"forminator-field-checkbox-2-8-6a937b448869e\" class=\"forminator-checkbox\" title=\"Lipo-Double Chin\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Lipo-Double-Chin\" id=\"forminator-field-checkbox-2-8-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-2-8-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lipo-Double Chin<\/span><\/label><\/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-3-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-3-6a937b448869e-label\" class=\"forminator-label\">Breast Surgery<\/span><label id=\"forminator-field-checkbox-3-1-6a937b448869e-label\" for=\"forminator-field-checkbox-3-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Breast Surgery\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breast Surgery<\/span><\/label><label id=\"forminator-field-checkbox-3-2-6a937b448869e-label\" for=\"forminator-field-checkbox-3-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Breast Augmentation\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breast Augmentation<\/span><\/label><label id=\"forminator-field-checkbox-3-3-6a937b448869e-label\" for=\"forminator-field-checkbox-3-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Implant Replacement\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Implant-Replacement\" id=\"forminator-field-checkbox-3-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Implant Replacement<\/span><\/label><label id=\"forminator-field-checkbox-3-4-6a937b448869e-label\" for=\"forminator-field-checkbox-3-4-6a937b448869e\" class=\"forminator-checkbox\" title=\"Breast Lift\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Breast-Lift\" id=\"forminator-field-checkbox-3-4-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-4-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breast Lift<\/span><\/label><label id=\"forminator-field-checkbox-3-5-6a937b448869e-label\" for=\"forminator-field-checkbox-3-5-6a937b448869e\" class=\"forminator-checkbox\" title=\"Breast Reduction\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Breast-Reduction\" id=\"forminator-field-checkbox-3-5-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-5-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Breast Reduction<\/span><\/label><label id=\"forminator-field-checkbox-3-6-6a937b448869e-label\" for=\"forminator-field-checkbox-3-6-6a937b448869e\" class=\"forminator-checkbox\" title=\"Gynecomastia (reduction of breast volume for men)\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Gynecomastia-(reduction-of-breast-volume-for-men)\" id=\"forminator-field-checkbox-3-6-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-6-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Gynecomastia (reduction of breast volume for men)<\/span><\/label><label id=\"forminator-field-checkbox-3-7-6a937b448869e-label\" for=\"forminator-field-checkbox-3-7-6a937b448869e\" class=\"forminator-checkbox\" title=\"Capsulectomy\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Capsulectomy\" id=\"forminator-field-checkbox-3-7-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-3-7-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Capsulectomy<\/span><\/label><\/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\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-4-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-4-6a937b448869e-label\" class=\"forminator-label\">Body Surgery<\/span><label id=\"forminator-field-checkbox-4-1-6a937b448869e-label\" for=\"forminator-field-checkbox-4-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Mommy Makeover\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"one\" id=\"forminator-field-checkbox-4-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Mommy Makeover<\/span><\/label><label id=\"forminator-field-checkbox-4-2-6a937b448869e-label\" for=\"forminator-field-checkbox-4-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Gluteal Transfer (BBL)\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"two\" id=\"forminator-field-checkbox-4-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Gluteal Transfer (BBL)<\/span><\/label><label id=\"forminator-field-checkbox-4-3-6a937b448869e-label\" for=\"forminator-field-checkbox-4-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Liposuction\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Liposuction\" id=\"forminator-field-checkbox-4-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Liposuction<\/span><\/label><label id=\"forminator-field-checkbox-4-4-6a937b448869e-label\" for=\"forminator-field-checkbox-4-4-6a937b448869e\" class=\"forminator-checkbox\" title=\"360\u00ba Liposculpture with Etching\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"360\u00ba-Liposculpture-with-Etching\" id=\"forminator-field-checkbox-4-4-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-4-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">360\u00ba Liposculpture with Etching<\/span><\/label><label id=\"forminator-field-checkbox-4-5-6a937b448869e-label\" for=\"forminator-field-checkbox-4-5-6a937b448869e\" class=\"forminator-checkbox\" title=\"360\u00ba Liposculpture without Etching\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"360\u00ba-Liposculpture-without-Etching\" id=\"forminator-field-checkbox-4-5-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-5-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">360\u00ba Liposculpture without Etching<\/span><\/label><label id=\"forminator-field-checkbox-4-6-6a937b448869e-label\" for=\"forminator-field-checkbox-4-6-6a937b448869e\" class=\"forminator-checkbox\" title=\"Fat Transfer to Buttocks and Hips\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Fat-Transfer-to-Buttocks-and-Hips\" id=\"forminator-field-checkbox-4-6-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-6-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fat Transfer to Buttocks and Hips<\/span><\/label><label id=\"forminator-field-checkbox-4-7-6a937b448869e-label\" for=\"forminator-field-checkbox-4-7-6a937b448869e\" class=\"forminator-checkbox\" title=\"Anterior Lipectomy\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Anterior-Lipectomy\" id=\"forminator-field-checkbox-4-7-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-7-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Anterior Lipectomy<\/span><\/label><label id=\"forminator-field-checkbox-4-8-6a937b448869e-label\" for=\"forminator-field-checkbox-4-8-6a937b448869e\" class=\"forminator-checkbox\" title=\"Extended Lipectomy\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Extended-Lipectomy\" id=\"forminator-field-checkbox-4-8-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-8-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Extended Lipectomy<\/span><\/label><label id=\"forminator-field-checkbox-4-9-6a937b448869e-label\" for=\"forminator-field-checkbox-4-9-6a937b448869e\" class=\"forminator-checkbox\" title=\"Circular Lipectomy\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Circular-Lipectomy\" id=\"forminator-field-checkbox-4-9-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-9-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Circular Lipectomy<\/span><\/label><label id=\"forminator-field-checkbox-4-10-6a937b448869e-label\" for=\"forminator-field-checkbox-4-10-6a937b448869e\" class=\"forminator-checkbox\" title=\"Abdominoplasty\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Abdominoplasty\" id=\"forminator-field-checkbox-4-10-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-10-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Abdominoplasty<\/span><\/label><label id=\"forminator-field-checkbox-4-11-6a937b448869e-label\" for=\"forminator-field-checkbox-4-11-6a937b448869e\" class=\"forminator-checkbox\" title=\"Labioplasty\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Labioplasty\" id=\"forminator-field-checkbox-4-11-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-11-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Labioplasty<\/span><\/label><label id=\"forminator-field-checkbox-4-12-6a937b448869e-label\" for=\"forminator-field-checkbox-4-12-6a937b448869e\" class=\"forminator-checkbox\" title=\"Torsoplasty\"><input type=\"checkbox\" name=\"checkbox-4[]\" value=\"Torsoplasty\" id=\"forminator-field-checkbox-4-12-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-4-12-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Torsoplasty<\/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-5-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-5-6a937b448869e-label\" class=\"forminator-label\">For Weight Loss<\/span><label id=\"forminator-field-checkbox-5-1-6a937b448869e-label\" for=\"forminator-field-checkbox-5-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Upper Body Lift\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"one\" id=\"forminator-field-checkbox-5-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-5-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Upper Body Lift<\/span><\/label><label id=\"forminator-field-checkbox-5-2-6a937b448869e-label\" for=\"forminator-field-checkbox-5-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Lower Body Lift\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"two\" id=\"forminator-field-checkbox-5-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-5-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Lower Body Lift<\/span><\/label><label id=\"forminator-field-checkbox-5-3-6a937b448869e-label\" for=\"forminator-field-checkbox-5-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Thigh Lift\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Thigh-Lift\" id=\"forminator-field-checkbox-5-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-5-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Thigh Lift<\/span><\/label><label id=\"forminator-field-checkbox-5-4-6a937b448869e-label\" for=\"forminator-field-checkbox-5-4-6a937b448869e\" class=\"forminator-checkbox\" title=\"Arm Lift\"><input type=\"checkbox\" name=\"checkbox-5[]\" value=\"Arm-Lift\" id=\"forminator-field-checkbox-5-4-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-5-4-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Arm Lift<\/span><\/label><\/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-6-6a937b448869e-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-6-6a937b448869e-label\" class=\"forminator-label\">Non-surgical<\/span><label id=\"forminator-field-checkbox-6-1-6a937b448869e-label\" for=\"forminator-field-checkbox-6-1-6a937b448869e\" class=\"forminator-checkbox\" title=\"Fillers\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"one\" id=\"forminator-field-checkbox-6-1-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-6-1-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Fillers<\/span><\/label><label id=\"forminator-field-checkbox-6-2-6a937b448869e-label\" for=\"forminator-field-checkbox-6-2-6a937b448869e\" class=\"forminator-checkbox\" title=\"Vaginal Rejuvenation\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"two\" id=\"forminator-field-checkbox-6-2-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-6-2-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Vaginal Rejuvenation<\/span><\/label><label id=\"forminator-field-checkbox-6-3-6a937b448869e-label\" for=\"forminator-field-checkbox-6-3-6a937b448869e\" class=\"forminator-checkbox\" title=\"Facial Rejuvenation\"><input type=\"checkbox\" name=\"checkbox-6[]\" value=\"Facial-Rejuvenation\" id=\"forminator-field-checkbox-6-3-6a937b448869e\" aria-labelledby=\"forminator-field-checkbox-6-3-6a937b448869e-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Facial Rejuvenation<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_6a937b448869e\" id=\"forminator-field-text-23_6a937b448869e-label\" class=\"forminator-label\">What part of your body would you like to primarily improve? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_6a937b448869e\" id=\"forminator-field-text-24_6a937b448869e-label\" class=\"forminator-label\">Do you have a maximum budget? If so, please mention your estimated maximum budget. <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_6a937b448869e\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-8\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-8-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"8\"\n\t\t\t\tdata-label=\"8\"\n\t\t\t\tdata-actual-label=\"9\"\n\t\t\t\tdata-name=\"page-break-9\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><label class=\"forminator-label\">Comments<\/label><div role=\"listitem\" class=\"Qr7Oae pQK2A\">\n<div class=\"vfQisd Q8wTDd OIC90c\">(Questions, Considerations, Etc.)<\/div>\n<\/div>\n<div role=\"listitem\" class=\"Qr7Oae\">\n<div data-params=\"%.@.[611641667,&quot;Criteria and Comments&quot;,null,0,[[1997090382,null,false,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,&quot;Criteria and Comments&quot;]],&quot;i1&quot;,&quot;i2&quot;,&quot;i3&quot;,false,&quot;i4&quot;]\">\n<div class=\"geS5n\">\n<div class=\"z12JJ\">\n<div class=\"M4DNQ\">\n<div role=\"heading\" class=\"HoXoMd D1wxyf RjsPE\" id=\"i1\">&nbsp;<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a937b448869e\" id=\"forminator-field-textarea-3_6a937b448869e-label\" class=\"forminator-label\">Criteria and Comments<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a937b448869e\" class=\"forminator-textarea\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><div\n\t\t\t\ttabindex=\"-1\"\n\t\t\t\trole=\"tabpanel\"\n\t\t\t\tid=\"forminator-custom-form-718--page-9\"\n\t\t\t\tclass=\"forminator-pagination\"\n\t\t\t\taria-labelledby=\"forminator-custom-form-718--page-9-label\"\n\t\t\t\taria-hidden=\"true\"\n\t\t\t\tdata-step=\"9\"\n\t\t\t\tdata-label=\"9\"\n\t\t\t\tdata-actual-label=\"Page 10\"\n\t\t\t\tdata-name=\"\"\n\t\t\t\thidden\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><label class=\"forminator-label\">Photographs Instructions<\/label><p>Please follow the instructions for a prompt and accurate assessment. Fully expose the areas of interest, allowing the doctor to have a clear view for evaluation.<\/p>\n<p><b>\u2022 <u>It is not necessary to capture your face in the images unless it is an area of interest for your procedures.<\/u><\/b><\/p>\n<p><b>\u2022<u> For liposuction and abdominoplasty, photos should be in underwear, without covering the abdomen. <\/u><\/b><\/p>\n<div>\n<div>\n<div>\n<div>\n<div>\n<div>\n<div>\n<p>\u2022<u><b> In the case of breast evaluation, without a bra.<\/b><\/u><\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-6\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-6\"><label class=\"forminator-label\">Facial procedures<\/label><div class=\"pYfr3c\">\n<div class=\"g53bl\">\n<div dir=\"auto\" class=\"cTDvob D1wxyf RjsPE\"><span class=\"M7eMe\">Example for <b>facial procedures<\/b><br><\/span><\/div>\n<\/div>\n<\/div>\n<p><img decoding=\"async\" alt=\"Profile Picture\" src=\"https:\/\/lh7-rt.googleusercontent.com\/formsz\/AN7BsVDlMoTylW4-JXvIhX3Wsa9vPS-wfOoL3b6sZfA0ZPaCrSvieG1T6USKbyGF4-RMKdzd0-aM3pN0kasQkh78ZuR8dqpwWHslI2U3Obk0e-Gngs_hB7-5COkI81ZpfZC5Kjeb3BvAZiRcIBBfT_WUFR9S=w2320?key=WqTX2oTnCiI_0LaOeui7LA\"><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-7\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-7\"><label class=\"forminator-label\">Frontal view, profile view, and back view with arms extended.<\/label><div class=\"pYfr3c\">\n<div class=\"g53bl\">\n<div dir=\"auto\" class=\"cTDvob D1wxyf RjsPE\">\n<p><b>Frontal view,<\/b>&nbsp;<b>profile view<\/b>, and&nbsp;<b>back view<\/b>&nbsp;with arms extended.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<p><img decoding=\"async\" alt=\"Profile Picture\" src=\"https:\/\/lh7-rt.googleusercontent.com\/formsz\/AN7BsVD9rR6baOpz9TTHitmLdk875RtKiXTOZieO0ItAVcTbD5afHJjyhQI5eUtnazvVIAPQZK3uzQMmonOKqDlngedF7MF1VCTPGaUPIyqAaCup_hYHWfs3hGpvTawUaRDDCriNsHaZSzTIUJiBJ-9yxyO2SA=w1148?key=WqTX2oTnCiI_0LaOeui7LA\"><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-8\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-8\"><label class=\"forminator-label\">Arms extended as seen in the image.<\/label><div class=\"pYfr3c\">\n<div class=\"g53bl\">\n<div dir=\"auto\" class=\"cTDvob D1wxyf RjsPE\"><span class=\"M7eMe\">Arms extended&nbsp;<b>as seen in the image.<\/b><\/span><\/div>\n<\/div>\n<\/div>\n\n<img decoding=\"async\" alt=\"Profile Picture\" src=\"https:\/\/lh7-rt.googleusercontent.com\/formsz\/AN7BsVBGVkotZp61OQDpCbSyQDTBwq4DJvSUmJwUty57eh1Qe5eEjNqyaTG_0-qRrTyX8J4ZlwbdtxWAYGV9oRqn00osjTw8hd7ABVhDoTW130ouQDOPJ0owfwD5ls84q71RQVprorJ9EMPR1KITpmW3GS6jiw=w1034?key=WqTX2oTnCiI_0LaOeui7LA\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-9\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-9\"><label class=\"forminator-label\">Flexion<\/label><div class=\"pYfr3c\">\n<div class=\"g53bl\">\n<div dir=\"auto\" class=\"cTDvob D1wxyf RjsPE\">\n<p><b>Two<\/b>&nbsp;additional photos in flexion to observe the degree of sagging,&nbsp;<b>in both profiles.<\/b><\/p>\n<\/div>\n<\/div>\n<\/div>\n<p><img decoding=\"async\" alt=\"Profile Picture\" src=\"https:\/\/lh7-rt.googleusercontent.com\/formsz\/AN7BsVBVRIOA5YtvI0c5J4xVGjqKh2LgpYBD1LFD7W3vcKZXcyK7i5rYiMKzIjDQRqJgQ-V30ZMAemSgTk7JQx3HpjfZO31WogXwRELRBcjYkB6LMVaE5iBOQ8f3_fIWTHYdfHSJE4_gPH_GcI_oT61yh-dPEg=w854?key=WqTX2oTnCiI_0LaOeui7LA\"><\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a937b448869e\" id=\"forminator-field-upload-1_6a937b448869e-label\" class=\"forminator-label\">Frontal View<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6a937b448869e\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6a937b448869e\" class=\"forminator-input-file\" 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