{"id":3569,"date":"2023-06-18T02:38:41","date_gmt":"2023-06-18T02:38:41","guid":{"rendered":"https:\/\/www.bruleehair.com\/datos\/?page_id=3569"},"modified":"2023-07-19T01:34:50","modified_gmt":"2023-07-19T01:34:50","slug":"diagnostico-y-consentimiento-informado","status":"publish","type":"page","link":"https:\/\/www.bruleehair.com\/datos\/diagnostico-y-consentimiento-informado\/","title":{"rendered":"Diagn\u00f3stico y Consentimiento Informado"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Diagn\u00f3stico y Consentimiento Informado<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; se\u00f1ala los campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/datos\/wp-json\/wp\/v2\/pages\/3569' data-formid='3' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_above description_below'><div id=\"field_3_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_10\" ><h3 class=\"gsection_title\">Diagn\u00f3stico Capilar y Observaciones<\/h3><\/div><div id=\"field_3_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_47\" ><label class='gfield_label gform-field-label' for='input_3_47'>Profesional que aplica el tratamiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_3_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='-' >-<\/option><option value='LAURA CASTA\u00d1O' >LAURA CASTA\u00d1O<\/option><option value='BLADIMIR ESCALANTE' >BLADIMIR ESCALANTE<\/option><option value='BRAYAN CASTELLANOS' >BRAYAN CASTELLANOS<\/option><option value='CAROLINA SANCHEZ' >CAROLINA SANCHEZ<\/option><option value='CESAR BARRETO' >CESAR BARRETO<\/option><option value='CHRISTIAN ROJAS' >CHRISTIAN ROJAS<\/option><option value='CRISTIAN CUELLAR' >CRISTIAN CUELLAR<\/option><option value='DANIEL STEVEN BERMEO' >DANIEL STEVEN BERMEO<\/option><option value='FERNANDA MEDINA' >FERNANDA MEDINA<\/option><option value='GABRIEL  YOPASA' >GABRIEL  YOPASA<\/option><option value='HERNANDO OSPINA' >HERNANDO OSPINA<\/option><option value='ISAAC ANTONIO GUEVARA' >ISAAC ANTONIO GUEVARA<\/option><option value='JHONIER HERNANDEZ' >JHONIER HERNANDEZ<\/option><option value='JUAN SEBASTIAN SILVA' >JUAN SEBASTIAN SILVA<\/option><option value='LEIDY ROJAS' >LEIDY ROJAS<\/option><option value='KELVI HERNANDEZ' >KELVI HERNANDEZ<\/option><option value='MAURICIO ARIZA' >MAURICIO ARIZA<\/option><option value='MAYDI SANGUINO' >MAYDI SANGUINO<\/option><option value='MILTON GALINDEZ' >MILTON GALINDEZ<\/option><option value='NATALY MALDONADO' >NATALY MALDONADO<\/option><option value='PABLO INFANTE' >PABLO INFANTE<\/option><option value='SEBASTIAN PELAEZ' >SEBASTIAN PELAEZ<\/option><option value='SEBASTIAN TAPIAS' >SEBASTIAN TAPIAS<\/option><option value='XIMENA ROSERO' >XIMENA ROSERO<\/option><option value='YADIRA HERNANDEZ' >YADIRA HERNANDEZ<\/option><option value='YEISON HERNANDEZ' >YEISON HERNANDEZ<\/option><\/select><\/div><\/div><div id=\"field_3_61\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_61\" ><label class='gfield_label gform-field-label' for='input_3_61'>Diagn\u00f3stico General del Profesional<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_61' id='input_3_61' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_3_63\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_63\" ><label class='gfield_label gform-field-label' for='input_3_63'>Orientaciones y\/o Observaciones del Profesional<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_3_63' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_52\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_3_52\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Por favor lea detenidamente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_3_52'>De manera consciente, libre y clara manifiesto que AUTORIZO a BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S., identificada con Nit 901.390.394-7 para que realice en mi cuerpo (cabello, u\u00f1as, bellos, cejas, y dem\u00e1s componentes del cuerpo humano) los procedimientos y\/o tratamientos est\u00e9ticos indicados en el final de este documento digital.<br \/>\n<br \/>\nCONFIRMO que se me han explicado en palabras sencillas y detalladamente, la naturaleza del (los) procedimientos que se me practicar\u00e1n y sus posibles efectos; de esa misma forma los mecanismos de aplicaci\u00f3n, de acci\u00f3n, toda contraindicaci\u00f3n, restricciones, riesgos o complicaciones posibles que se pueden presentar de manera inmediata o en el periodo post-tratamiento.<br \/>\n<br \/>\nDe igual manera se me ha informado que la duraci\u00f3n y\/o porcentaje de efecto de los resultados obtenidos del o los procedimientos, pueden variar en el tiempo teniendo en cuenta factores ambientales y\/o org\u00e1nicos, as\u00ed mismo que los factores que puedan afectar el resultado propio de este procedimiento son inciertos incluso para el profesional a cargo del tratamiento, sin embargo, me comprometo a seguir con las indicaciones brindadas por los profesionales designados de BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S., buscando el mejor resultado para m\u00ed.<br \/>\n<br \/>\nACEPTO que si mi tratamiento y\/o procedimiento requiere la aplicaci\u00f3n de productos adicionales o procedimientos diferentes a los inherentes de aquellos que se me adelanten por parte de BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S. para lograr el efecto que deseo, estos ser\u00e1n sufragados en su totalidad por mi cuenta una vez identificada la necesidad y se me notifique.<br \/>\n<br \/>\nACEPTO Y DECLARO expresamente que comprendo que los procesos que se me realizar\u00e1n no pueden garantizar resultados exactos, por lo que la obligaci\u00f3n de quien participe de mi atenci\u00f3n en la ejecuci\u00f3n de los procedimientos que corresponden al\/los tratamientos\/s elegido\/s ser\u00e1 siempre de medios y no de resultados, sin embargo, para efectos de reclamaci\u00f3n esta se har\u00e1 exclusivamente a la obra de mano contratada, eximiendo de cualquier perjuicio a BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S. y a los productos provistos para el servicio.<br \/>\n<br \/>\nACEPTO Y DECLARO que tengo claridad frente a los valores del(los) servicio(s) prestado(s) y que por consiguiente estoy de acuerdo con los mismos, absteni\u00e9ndome de cualquier reclamaci\u00f3n por el servicio prestado o los productos empleados por los profesionales designados por BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S., as\u00ed mismo, me comprometo a seguir puntualmente las instrucciones compartidas para antes, durante y despu\u00e9s del\/los tratamientos\/s\u00a0 que se me realicen, de\u00a0 igual manera me comprometo a suministrar la informaci\u00f3n necesaria para la construcci\u00f3n de una ficha informativa y a NO omitir ni alterar ning\u00fan dato personal ni antecedente m\u00e9dico o de salud que pueda llegar a verse comprometido por la aplicaci\u00f3n de productos y\/o tratamientos.<br \/>\n<br \/>\nDoy fe de no haber omitido o alterado datos al exponer mi historial de salud, espec\u00edficamente los referidos a embarazos, alergias y\/o enfermedades que puedan verse afectadas o agravadas debido al procedimiento a aplicar, en consecuencia, de la veracidad de los datos informados en general ACEPTO la responsabilidad civil y penal que me asiste por omisi\u00f3n o manifestaci\u00f3n err\u00f3nea sobre mi estado real de salud a lo expuestos anteriormente.<br \/>\n<br \/>\nDe la misma forma autorizo a BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S., identificada con Nit 901.390.394-7 para que haga el uso y tratamiento de mis derechos de imagen para incluirlos sobre fotograf\u00edas y producciones audiovisuales (videos); as\u00ed como de los Derechos de Autor; los Derechos Conexos y en general todos aquellos derechos de propiedad intelectual que tengan que ver con el derecho de imagen.<br \/>\n<br \/>\nTengo claro que mis datos ser\u00e1n tratados conforme a la legislaci\u00f3n colombiana. Ley de protecci\u00f3n de datos 1581 del 2012 y su Decreto Reglamentario 1377 de 2013. De igual forma, autorizo el tratamiento, manejo, traslado, correcci\u00f3n y actualizaci\u00f3n de mis datos personales para los fines previstos a la entidad BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S. Por la presente, yo y mis sucesores o cesionarios eximimos a BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S., a sus colaboradores, empleados, arrendatarios y a cualquier otra persona que participe en mi atenci\u00f3n, y a sus sucesores y cesionarios, de toda responsabilidad ante cualquier reclamo por da\u00f1os o de indemnizaci\u00f3n que surja de las actividades autorizadas por este acuerdo. La responsabilidad de la compa\u00f1\u00eda se limita a tener los medios que garanticen esta seguridad. Inform\u00e1ndoles tambi\u00e9n que usted(es) tiene(n) el derecho de solicitar, actualizar, modificar y suprimir en cualquier momento su informaci\u00f3n, estos derechos se pueden hacer factibles a trav\u00e9s del correo: info@bruleehair.com<br \/>\n<br \/>\nEsta autorizaci\u00f3n se regir\u00e1 por las normas legales aplicables y en particular por las siguientes:<br \/>\n<br \/>\nEste video\/foto podr\u00e1 ser utilizado con fines publicitarios en las diferentes plataformas y redes sociales de BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S.<br \/>\nEste video\/foto en ning\u00fan momento ser\u00e1 utilizado para objetivos distintos. BR\u00dbL\u00c9E BY KELVY &amp; YADI S.A.S. queda exenta de cualquier responsabilidad CIVIL o PENAL que se pueda derivar de la presente actividad con la firma de la autorizaci\u00f3n.<br \/>\nLa presente autorizaci\u00f3n no tiene \u00e1mbito geogr\u00e1fico determinado, por lo que las im\u00e1genes en las que aparezca podr\u00e1n ser utilizadas en el territorio del mundo, as\u00ed mismo, tampoco tiene ning\u00fan l\u00edmite de tiempo para su concesi\u00f3n, ni para explotaci\u00f3n de las im\u00e1genes, o parte de estas, por lo que mi autorizaci\u00f3n se considera concedida por un plazo de tiempo ilimitado.<br \/>\n<br \/>\nEn mi calidad de persona natural autorizo el uso de derechos de imagen sobre fotograf\u00edas y producci\u00f3n audiovisual (videos), as\u00ed como los patrimoniales de autor y derechos conexos, y en general todos aquellos derechos de propiedad intelectual que tengan que ver con el derecho de imagen.<br \/>\n<br \/>\nEn constancia de lo anterior, me identifico y firmo digitalmente el presente documento digital:<\/div><div class='ginput_container ginput_container_consent'><input name='input_52.1' id='input_3_52_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_3_52\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_3_52_1' >De manera consciente y libre acepto el consentimiento informado.<\/label><input type='hidden' name='input_52.2' value='De manera consciente y libre acepto el consentimiento informado.' class='gform_hidden' \/><input type='hidden' name='input_52.3' value='7' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_3_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_62\" ><h3 class=\"gsection_title\">Procedimientos \/ Tratamientos Est\u00e9ticos<\/h3><div class='gsection_description' id='gfield_description_3_62'>Por favor marque a continuaci\u00f3n los procedimientos o tratamientos est\u00e9ticos que autoriza sean aplicados.<\/div><\/div><div id=\"field_3_60\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_60\" ><label class='gfield_label gform-field-label' for='input_3_60'>Indiqu\u00e9 qu\u00e9 tipo de procedimiento o tratamiento se aplicar\u00e1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_3_60' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='-' >-<\/option><option value='hair' >Cabello \/ Maquillaje<\/option><option value='nails' >Manicure \/ Pedicure<\/option><option value='ambas' >Ambas<\/option><\/select><\/div><\/div><fieldset id=\"field_3_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_49\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >#LOVEFORHAIR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_49'><div class='gchoice gchoice_3_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Asesor\u00eda de Imagen'  id='choice_3_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_1' id='label_3_49_1' class='gform-field-label gform-field-label--type-inline'>Asesor\u00eda de Imagen<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Color'  id='choice_3_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_2' id='label_3_49_2' class='gform-field-label gform-field-label--type-inline'>Color<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Corte'  id='choice_3_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_3' id='label_3_49_3' class='gform-field-label gform-field-label--type-inline'>Corte<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Especialistas en Novias'  id='choice_3_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_4' id='label_3_49_4' class='gform-field-label gform-field-label--type-inline'>Especialistas en Novias<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.5' type='checkbox'  value='Keratina'  id='choice_3_49_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_5' id='label_3_49_5' class='gform-field-label gform-field-label--type-inline'>Keratina<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.6' type='checkbox'  value='Maquillaje'  id='choice_3_49_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_6' id='label_3_49_6' class='gform-field-label gform-field-label--type-inline'>Maquillaje<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_49_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.7' type='checkbox'  value='Tratamientos Capilares'  id='choice_3_49_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_49_7' id='label_3_49_7' class='gform-field-label gform-field-label--type-inline'>Tratamientos Capilares<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_50\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >#NAILART<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_50'><div class='gchoice gchoice_3_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Base Rubber'  id='choice_3_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_1' id='label_3_50_1' class='gform-field-label gform-field-label--type-inline'>Base Rubber<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Esmaltado Semipermanente'  id='choice_3_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_2' id='label_3_50_2' class='gform-field-label gform-field-label--type-inline'>Esmaltado Semipermanente<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Gel Estructural'  id='choice_3_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_3' id='label_3_50_3' class='gform-field-label gform-field-label--type-inline'>Gel Estructural<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Kapping'  id='choice_3_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_4' id='label_3_50_4' class='gform-field-label gform-field-label--type-inline'>Kapping<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.5' type='checkbox'  value='Polygel'  id='choice_3_50_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_5' id='label_3_50_5' class='gform-field-label gform-field-label--type-inline'>Polygel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.6' type='checkbox'  value='Press On Acr\u00edlico'  id='choice_3_50_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_6' id='label_3_50_6' class='gform-field-label gform-field-label--type-inline'>Press On Acr\u00edlico<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.7' type='checkbox'  value='Secado R\u00e1pido'  id='choice_3_50_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_7' id='label_3_50_7' class='gform-field-label gform-field-label--type-inline'>Secado R\u00e1pido<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_3_50_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.8' type='checkbox'  value='Tradicional'  id='choice_3_50_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_50_8' id='label_3_50_8' class='gform-field-label gform-field-label--type-inline'>Tradicional<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_67\" ><h3 class=\"gsection_title\">Valores del Servicio<\/h3><div class='gsection_description' id='gfield_description_3_67'>Todos los servicios se cobran por separado:\nTratamientos desde 130.000 hasta 300.000\n\/ Shampoo 20.000\n\/ Peinado Blower 40.000\n\/ Ondas 60.000\n\/ Corte 50.000 - 60.000<\/div><\/div><div id=\"field_3_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_68\" ><label class='gfield_label gform-field-label' for='input_3_68'>Valor Dise\u00f1o del Color<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_3_68' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_70\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_70\" ><label class='gfield_label gform-field-label' for='input_3_70'>L\u00ednea de Productos Recomendada<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_70' id='input_3_70' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-<\/option><option value='KERASTASE - BLOND ABSOLU' >KERASTASE - BLOND ABSOLU<\/option><option value='KERASTASE - CHROMA ABSOLU' >KERASTASE - CHROMA ABSOLU<\/option><option value='KERASTASE - CHRONOLOGISTE' >KERASTASE - CHRONOLOGISTE<\/option><option value='KERASTASE - CURL MANIFESTO' >KERASTASE - CURL MANIFESTO<\/option><option value='KERASTASE - GENESIS' >KERASTASE - GENESIS<\/option><option value='KERASTASE - NUTRITIVE' >KERASTASE - NUTRITIVE<\/option><option value='KERASTASE - RESISTANCE' >KERASTASE - RESISTANCE<\/option><option value='KERASTASE - SPECIFIQUE' >KERASTASE - SPECIFIQUE<\/option><option value='KERASTASE - SYMBIOSE' >KERASTASE - SYMBIOSE<\/option><option value='KERASTASE - THERAPISTE' >KERASTASE - THERAPISTE<\/option><option value='OLAPLEX - OLAPLEX' >OLAPLEX - OLAPLEX<\/option><option value='OLAPLEX - PASO 0 Y 3' >OLAPLEX - PASO 0 Y 3<\/option><option value='OLAPLEX - PASO 4 Y 5' >OLAPLEX - PASO 4 Y 5<\/option><option value='WELLA - KIT BRILLIANCE' >WELLA - KIT BRILLIANCE<\/option><option value='WELLA - KIT COLOR ELEMENTS' >WELLA - KIT COLOR ELEMENTS<\/option><option value='WELLA - KIT COLOR FUSION' >WELLA - KIT COLOR FUSION<\/option><option value='WELLA - KIT COLOR MOTION' >WELLA - KIT COLOR MOTION<\/option><option value='WELLA - KIT NUTRI-ENRICH' >WELLA - KIT NUTRI-ENRICH<\/option><option value='WELLA - KIT NUTRICURLS' >WELLA - KIT NUTRICURLS<\/option><option value='WELLA - ULTIMATE REPAIR' >WELLA - ULTIMATE REPAIR<\/option><option value='OTROS' >OTROS<\/option><\/select><\/div><\/div><div id=\"field_3_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_55\" ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_3_55'>Agradecemos leer el texto completo del Consentimiento Informado Tratamiento Est\u00e9tico y Autorizaci\u00f3n de Uso de Imagen en el siguiente<span style=\"text-decoration: underline\"><strong> <a href=\"https:\/\/www.bruleehair.com\/datos\/consentimiento-informado-tratamiento-estetico-y-autorizacion-de-uso-de-imagen\/\" target=\"_blank\" rel=\"noopener\">\u276f enlace \u276e<\/a><\/strong><\/span><\/div><\/div><fieldset id=\"field_3_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_53\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Autorizaci\u00f3n del procedimiento a realizar.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_53'><div class='gchoice gchoice_3_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Autorizaci\u00f3n del procedimiento a realizar.'  id='choice_3_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_53_1' id='label_3_53_1' class='gform-field-label gform-field-label--type-inline'>Autorizaci\u00f3n del procedimiento a realizar.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_56\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Conocimiento de los procedimientos que se van a realizar, sus efectos; las recomendaciones y cuidados sugeridos por el profesional<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_56'><div class='gchoice gchoice_3_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Conocimiento de los procedimientos que se van a realizar, sus efectos; las recomendaciones y cuidados sugeridos por el profesional.'  id='choice_3_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_56_1' id='label_3_56_1' class='gform-field-label gform-field-label--type-inline'>Conocimiento de los procedimientos que se van a realizar, sus efectos; las recomendaciones y cuidados sugeridos por el profesional.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_57\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aceptaci\u00f3n y confirmaci\u00f3n del diagn\u00f3stico capilar realizado por el profesional.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_57'><div class='gchoice gchoice_3_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Aceptaci\u00f3n y confirmaci\u00f3n del diagn\u00f3stico capilar realizado por el profesional.'  id='choice_3_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_57_1' id='label_3_57_1' class='gform-field-label gform-field-label--type-inline'>Aceptaci\u00f3n y confirmaci\u00f3n del diagn\u00f3stico capilar realizado por el profesional.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_58\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Autorizaci\u00f3n del uso y tratamiento de imagen (fotos y videos del antes, durante y despu\u00e9s del procedimiento realizado).<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_58'><div class='gchoice gchoice_3_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Autorizaci\u00f3n del uso y tratamiento de imagen (fotos y videos del antes, durante y despu\u00e9s del procedimiento realizado).'  id='choice_3_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_58_1' id='label_3_58_1' class='gform-field-label gform-field-label--type-inline'>Autorizaci\u00f3n del uso y tratamiento de imagen (fotos y videos del antes, durante y despu\u00e9s del procedimiento realizado).<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_59\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aceptaci\u00f3n de los valores de los servicios prestados.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_59'><div class='gchoice gchoice_3_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Aceptaci\u00f3n de los valores de los servicios prestados.'  id='choice_3_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_59_1' id='label_3_59_1' class='gform-field-label gform-field-label--type-inline'>Aceptaci\u00f3n de los valores de los servicios prestados.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_66\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aceptaci\u00f3n lectura consentimiento informado.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_66'><div class='gchoice gchoice_3_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Confirmo que he le\u00eddo y acepto lo contenido en el &lt;span style=&quot;text-decoration: underline&quot;&gt;&lt;strong&gt; &lt;a href=&quot;https:\/\/www.bruleehair.com\/datos\/consentimiento-informado-tratamiento-estetico-y-autorizacion-de-uso-de-imagen\/&quot; target=&quot;_blank&quot; rel=&quot;noopener&quot;&gt;\u276f Consentimiento Informado \u276e&lt;\/a&gt;&lt;\/strong&gt;&lt;\/span&gt;'  id='choice_3_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>Confirmo que he le\u00eddo y acepto lo contenido en el <span style=\"text-decoration: underline\"><strong> <a href=\"https:\/\/www.bruleehair.com\/datos\/consentimiento-informado-tratamiento-estetico-y-autorizacion-de-uso-de-imagen\/\" target=\"_blank\" rel=\"noopener\">\u276f Consentimiento Informado \u276e<\/a><\/strong><\/span><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_79\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_79\" ><label class='gfield_label gform-field-label' for='input_3_79'>Por favor indique si es al\u00e9rgica(o) a alguno de los productos que ser\u00e1n aplicados\/empleados durante el servicio.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_79' id='input_3_79' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-<\/option><option value='S\u00ed' >S\u00ed<\/option><option value='No' >No<\/option><option value='' ><\/option><\/select><\/div><\/div><div id=\"field_3_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_80\" ><label class='gfield_label gform-field-label' for='input_3_80'>Por favor indique si en alg\u00fan procedimiento de color anterior present\u00f3 alguna reacci\u00f3n al\u00e9rgica.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_3_80' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-<\/option><option value='S\u00ed' >S\u00ed<\/option><option value='No' >No<\/option><option value='' ><\/option><\/select><\/div><\/div><div id=\"field_3_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_7\" ><h3 class=\"gsection_title\">Datos Personales Usuaria(o)<\/h3><\/div><fieldset id=\"field_3_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Identificaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_1'>\n                            \n                            <span id='input_3_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_1_3' class='gform-field-label gform-field-label--type-sub '>Nombres<\/label>\n                                                    <input type='text' name='input_1.3' id='input_3_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_3_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_1_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_1.6' id='input_3_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_20\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_20\" ><label class='gfield_label gform-field-label' for='input_3_20'>Tipo de Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_3_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-<\/option><option value='C\u00e9dula de Ciudadan\u00eda' >C\u00e9dula de Ciudadan\u00eda<\/option><option value='C\u00e9dula de Extranjer\u00eda' >C\u00e9dula de Extranjer\u00eda<\/option><option value='Documento Extranjero' >Documento Extranjero<\/option><option value='Pasaporte' >Pasaporte<\/option><option value='Tarjeta de Identidad' >Tarjeta de Identidad<\/option><\/select><\/div><\/div><div id=\"field_3_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_19\" ><label class='gfield_label gform-field-label' for='input_3_19'>N\u00famero de Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_3_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_21\" ><label class='gfield_label gform-field-label' for='input_3_21'>N\u00famero de Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_3_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_65\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_65\" ><label class='gfield_label gform-field-label' for='input_3_65'>Correo Electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_65' id='input_3_65' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_3_71\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full menor-edad field_sublabel_above gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_3_71\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Soy menor de edad.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_71'><div class='gchoice gchoice_3_71_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_71.1' type='checkbox'  value='Soy menor de edad'  id='choice_3_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_71_1' id='label_3_71_1' class='gform-field-label gform-field-label--type-inline'>Soy menor de edad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_51\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_51\" ><label class='gfield_label gform-field-label' for='input_3_51'>Firma<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_3_51_Container' class='gfield_signature_container ginput_container' style='height:180px; width:350px; ' ><input type='hidden' class='gform_hidden' name='input_3_51_valid' id='input_3_51_valid' \/><canvas id='input_3_51' width='350' height='180'><\/canvas><\/div><\/div><\/div><div id=\"field_3_72\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_72\" ><h3 class=\"gsection_title\">Datos Personales Tutor o Adulto que autoriza el tratamiento<\/h3><\/div><fieldset id=\"field_3_73\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_73\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Identificaci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_73'>\n                            \n                            <span id='input_3_73_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_3_73_3' class='gform-field-label gform-field-label--type-sub '>Nombres<\/label>\n                                                    <input type='text' name='input_73.3' id='input_3_73_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_3_73_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_3_73_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                            <input type='text' name='input_73.6' id='input_3_73_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_74\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_74\" ><label class='gfield_label gform-field-label' for='input_3_74'>Tipo de Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_3_74' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>-<\/option><option value='C\u00e9dula de Ciudadan\u00eda' >C\u00e9dula de Ciudadan\u00eda<\/option><option value='C\u00e9dula de Extranjer\u00eda' >C\u00e9dula de Extranjer\u00eda<\/option><option value='Pasaporte' >Pasaporte<\/option><option value='Documento Extranjero' >Documento Extranjero<\/option><\/select><\/div><\/div><div id=\"field_3_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\" ><label class='gfield_label gform-field-label' for='input_3_75'>N\u00famero de Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_3_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_76\" ><label class='gfield_label gform-field-label' for='input_3_76'>N\u00famero de Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_3_76' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_77\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_3_77\" ><label class='gfield_label gform-field-label' for='input_3_77'>Correo Electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required 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