{"id":5107,"date":"2025-02-18T11:08:44","date_gmt":"2025-02-18T16:08:44","guid":{"rendered":"https:\/\/javiererasoortodoncia.com\/?page_id=5107"},"modified":"2025-10-22T06:18:35","modified_gmt":"2025-10-22T11:18:35","slug":"hc-eraso-2025","status":"publish","type":"page","link":"https:\/\/javiererasoortodoncia.com\/en\/hc-eraso-2025\/","title":{"rendered":"HC ERASO 2025"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"5107\" class=\"elementor elementor-5107\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-3a5656f elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"3a5656f\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-ff01ae5\" data-id=\"ff01ae5\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-67e8a12 elementor-widget elementor-widget-image\" data-id=\"67e8a12\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" width=\"300\" height=\"82\" src=\"https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200-300x82.png\" class=\"attachment-medium size-medium wp-image-2254\" alt=\"\" srcset=\"https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200-300x82.png 300w, https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200-1024x279.png 1024w, https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200-768x210.png 768w, https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200.png 1488w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2d677e8 elementor-widget elementor-widget-text-editor\" data-id=\"2d677e8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Por favor diligencia todos los campos y evita saltar informaci\u00f3n.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-402e283 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"402e283\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-5f6a44b\" data-id=\"5f6a44b\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5b2e7c9 elementor-button-align-center elementor-widget elementor-widget-form\" data-id=\"5b2e7c9\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Siguiente&quot;,&quot;step_previous_label&quot;:&quot;Anterior&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"DATOS HC ERASO\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"5107\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"5b2e7c9\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"HC ERASO 2025 - Javier Eraso Ortodoncia\" \/>\n\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"queried_id\" value=\"5107\"\/>\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6e240bd elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Datos Personales\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-name elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-name\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1. Nombre Profesional Tratante\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[name]\" id=\"form-field-name\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Javier Eraso\">Javier Eraso<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_365f82f elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_365f82f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1.1 Rethus\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_365f82f]\" id=\"form-field-field_365f82f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CCO-012153\">CCO-012153<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9831318 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9831318\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1.2 Lugar Atencion\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9831318]\" id=\"form-field-field_9831318\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Javier Eraso Ortodoncia\">Javier Eraso Ortodoncia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Guillermo Rojas Odontolog\u00eda\">Guillermo Rojas Odontolog\u00eda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Odontomedic\">Odontomedic<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b60d279 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b60d279\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2. Nombres y apellidos del paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b60d279]\" id=\"form-field-field_b60d279\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f1f0008 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f1f0008\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.1 Tipo documento paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f1f0008]\" id=\"form-field-field_f1f0008\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CC\">CC<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TI\">TI<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CEDULA EXTRANJERIA\">CEDULA EXTRANJERIA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OTRO\">OTRO<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6fafd42 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6fafd42\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.2 Numero documento paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6fafd42]\" id=\"form-field-field_6fafd42\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_2d144c5 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2d144c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.3 Fecha nacimiento paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_2d144c5]\" id=\"form-field-field_2d144c5\" class=\"elementor-field elementor-size-xs  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_acd1e08 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_acd1e08\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.4 # Telefono Paciente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_acd1e08]\" id=\"form-field-field_acd1e08\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c5f1f6f elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c5f1f6f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.5 Sexo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c5f1f6f]\" id=\"form-field-field_c5f1f6f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Femenino\">Femenino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Masculino\">Masculino<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Otro\">Otro<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1bafd03 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1bafd03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.6 Tipo de sangre\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1bafd03]\" id=\"form-field-field_1bafd03\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"A-\">A-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"A+\">A+<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AB-\">AB-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"AB+\">AB+<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"B-\">B-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"B+\">B+<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"O-\">O-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"O+\">O+<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ff8e4bc elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff8e4bc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.7 Estado civil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ff8e4bc]\" id=\"form-field-field_ff8e4bc\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Soltero\">Soltero<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Casado\">Casado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Uni\u00f3n libre\">Uni\u00f3n libre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Divorciado\">Divorciado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Viudo\">Viudo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Otros\">Otros<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_44a57bd elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_44a57bd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.8 Pais de nacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_44a57bd]\" id=\"form-field-field_44a57bd\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_28b8532 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_28b8532\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.9 Ciudad de nacimiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_28b8532]\" id=\"form-field-field_28b8532\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a544959 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a544959\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.10 Pais de domicilio\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a544959]\" id=\"form-field-field_a544959\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5ad0ffa elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5ad0ffa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.11 Ciudad de domicilio\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5ad0ffa]\" id=\"form-field-field_5ad0ffa\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a84606a elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a84606a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.12 Barrio domicilio\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a84606a]\" id=\"form-field-field_a84606a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fc01b41 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc01b41\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.13 Lugar de residencia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fc01b41]\" id=\"form-field-field_fc01b41\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9ed710d elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9ed710d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.14 Ocupaci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9ed710d]\" id=\"form-field-field_9ed710d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ff7814c elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff7814c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.15 Nombre EPS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ff7814c]\" id=\"form-field-field_ff7814c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0f7677e elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0f7677e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2.16 Tipo vinculaci\u00f3n EPS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0f7677e]\" id=\"form-field-field_0f7677e\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Contributivo\">Contributivo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Subsidiado\">Subsidiado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Beneficiario\">Beneficiario<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Otro\">Otro<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ba78026 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba78026\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3. Nombre y apellido acudiente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ba78026]\" id=\"form-field-field_ba78026\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_06dc894 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_06dc894\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3.1 Tipo documento acudiente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_06dc894]\" id=\"form-field-field_06dc894\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CC\">CC<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"TI\">TI<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"CEDULA EXTRANJERIA\">CEDULA EXTRANJERIA<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"OTRO\">OTRO<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_12a6c75 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12a6c75\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3.2 # Documento acudiente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_12a6c75]\" id=\"form-field-field_12a6c75\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ddd62d9 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ddd62d9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3.3 Parentesco\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ddd62d9]\" id=\"form-field-field_ddd62d9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_73c6e37 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_73c6e37\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3.4 # Telefono acudiente\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_73c6e37]\" id=\"form-field-field_73c6e37\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_7353028 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Anamnesis\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_499d141 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_499d141\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t4. Motivo de consulta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_499d141]\" id=\"form-field-field_499d141\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Colocar entre comillas &quot;&quot;\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_03e8b92 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_03e8b92\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t5. Alerta medica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_03e8b92]\" id=\"form-field-field_03e8b92\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Refiere\">No Refiere<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a5b4a99 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a5b4a99\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t5.1 Cual alerta medica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a5b4a99]\" id=\"form-field-field_a5b4a99\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_91869a5 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_91869a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t6. Toma alg\u00fan medicamento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_91869a5]\" id=\"form-field-field_91869a5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7816db8 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7816db8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t6.1 Cual medicamento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7816db8]\" id=\"form-field-field_7816db8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_74469b3 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_74469b3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t7. Al\u00e9rgico a algo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_74469b3]\" id=\"form-field-field_74469b3\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No \">No <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_babdd6b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_babdd6b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t7.1 A que es alergico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_babdd6b]\" id=\"form-field-field_babdd6b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3855ea2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3855ea2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t8. Antecedentes medicos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3855ea2]\" id=\"form-field-field_3855ea2\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Colocar entre comillas &quot;&quot;\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_64ebbe2 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_64ebbe2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t9.  Antecedentes odontologicos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_64ebbe2]\" id=\"form-field-field_64ebbe2\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Colocar entre comillas &quot;&quot;\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a8a7b2c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a8a7b2c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t10. Tratamiento de ortodoncia u ortopedia previo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a8a7b2c]\" id=\"form-field-field_a8a7b2c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3dee590 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3dee590\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t10.1 Hace cuanto y cual tratamiento tuvo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3dee590]\" id=\"form-field-field_3dee590\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_757afa8 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"An\u00e1lisis Radiografico\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3c06716 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3c06716\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11. Dientes retenidos o impactados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3c06716]\" id=\"form-field-field_3c06716\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_688310f elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_688310f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11.1 Donde dientes retenidos o impactados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_688310f]\" id=\"form-field-field_688310f\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_213459b elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_213459b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11.2 Cuantos dientes retenidos o impactados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_213459b]\" id=\"form-field-field_213459b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_34aebfa elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_34aebfa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t12. Dientes impactados NO 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_34aebfa]\" id=\"form-field-field_34aebfa\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_385393b elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_385393b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t12.1 Donde impactados NO 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_385393b]\" id=\"form-field-field_385393b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c623559 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c623559\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t12.2 Cuantos impactados NO 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c623559]\" id=\"form-field-field_c623559\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e198776 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e198776\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t13. Dientes faltantes No cong\u00e9nitos (Agenesia)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e198776]\" id=\"form-field-field_e198776\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_413be14 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_413be14\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t13.1 Donde faltantes No cong\u00e9nitos (Agenesia)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_413be14]\" id=\"form-field-field_413be14\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bd2559d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bd2559d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t13.2 Cuantos faltante No cong\u00e9nito (Agenesia)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bd2559d]\" id=\"form-field-field_bd2559d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0053649 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0053649\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t14. Dientes supernumerarios\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0053649]\" id=\"form-field-field_0053649\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d599d9c elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d599d9c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t14.1 Donde super numerarios\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d599d9c]\" id=\"form-field-field_d599d9c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bfc246a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bfc246a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t14.2 Cuantos super numerarios\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bfc246a]\" id=\"form-field-field_bfc246a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e598714 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e598714\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t15. Dientes anquilosados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e598714]\" id=\"form-field-field_e598714\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4f0da03 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4f0da03\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t15.1 Donde dientes anquilosados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4f0da03]\" id=\"form-field-field_4f0da03\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5a5d61e elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5a5d61e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t15.2 Cuantos dientes anquilosados\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5a5d61e]\" id=\"form-field-field_5a5d61e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_f52335d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f52335d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t16. Longitud radicular disminuida\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_f52335d]\" id=\"form-field-field_f52335d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_596b28a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_596b28a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t16.1 Donde longitud radicular disminuida\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_596b28a]\" id=\"form-field-field_596b28a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c2c448d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c2c448d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t16.2 Cuantos longitud radicular disminuida\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c2c448d]\" id=\"form-field-field_c2c448d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3d16a5d elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3d16a5d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t17. Raices severamente anguladas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3d16a5d]\" id=\"form-field-field_3d16a5d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cd776e2 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cd776e2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t17.1 Donde raiz severamente angulada\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cd776e2]\" id=\"form-field-field_cd776e2\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_04888de elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_04888de\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t17.2 Cuantas raiz severamente angulada\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_04888de]\" id=\"form-field-field_04888de\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_df43095 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_df43095\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t18. Perdida Osea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_df43095]\" id=\"form-field-field_df43095\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_565eab3 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_565eab3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t18.1 Donde perdida osea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_565eab3]\" id=\"form-field-field_565eab3\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b9d1393 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b9d1393\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t18.2 Cuantos con perdida osea\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b9d1393]\" id=\"form-field-field_b9d1393\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ff70457 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff70457\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t19. Falta de selle apical\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ff70457]\" id=\"form-field-field_ff70457\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_328dea6 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_328dea6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t19.1 Donde falta de selle apical\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_328dea6]\" id=\"form-field-field_328dea6\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_52dabb3 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_52dabb3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t19.2 Cuantos con falta de selle apical\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_52dabb3]\" id=\"form-field-field_52dabb3\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ba463aa elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba463aa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t20. Dientes perdidos No 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ba463aa]\" id=\"form-field-field_ba463aa\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b7f1a14 elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b7f1a14\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t20.1 Donde perdidos No 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b7f1a14]\" id=\"form-field-field_b7f1a14\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5a8682a elementor-col-33\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5a8682a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t20.2 Cuantos perdidos No 3ros molares\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5a8682a]\" id=\"form-field-field_5a8682a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_d4de58b elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d4de58b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t21. Observaciones endodonticas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_d4de58b]\" id=\"form-field-field_d4de58b\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9554e5e elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9554e5e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t21.1 Donde observaciones endodonticas\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9554e5e]\" id=\"form-field-field_9554e5e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5e0dc21 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5e0dc21\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t22. Observaciones rehabilitacion oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5e0dc21]\" id=\"form-field-field_5e0dc21\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ca31c13 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca31c13\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t22.1 Donde observaciones rehabilitacio oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ca31c13]\" id=\"form-field-field_ca31c13\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_373d802 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_373d802\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t23. Observaciones patologia oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_373d802]\" id=\"form-field-field_373d802\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d6ff986 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d6ff986\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t23. 1 Donde observaciones patologia oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d6ff986]\" id=\"form-field-field_d6ff986\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c61b861 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c61b861\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t24. Otras observaciones rx panoramica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c61b861]\" id=\"form-field-field_c61b861\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_234626a elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_234626a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t24.1 Que observaciones rx panoramica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_234626a]\" id=\"form-field-field_234626a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e6c823e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e6c823e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t25. SNA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e6c823e]\" id=\"form-field-field_e6c823e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_85fbce9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_85fbce9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t26. SNB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_85fbce9]\" id=\"form-field-field_85fbce9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7ec5ecb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7ec5ecb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t27. ANB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7ec5ecb]\" id=\"form-field-field_7ec5ecb\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_50568f5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_50568f5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t28. APDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_50568f5]\" id=\"form-field-field_50568f5\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_378b343 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_378b343\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t29. SN-MP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_378b343]\" id=\"form-field-field_378b343\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a6fb5f8 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6fb5f8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t30. FMA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a6fb5f8]\" id=\"form-field-field_a6fb5f8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9a5ee87 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a5ee87\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t31. FH-MP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9a5ee87]\" id=\"form-field-field_9a5ee87\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1bc6790 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1bc6790\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t32. LOWER AF\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1bc6790]\" id=\"form-field-field_1bc6790\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a9080a5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a9080a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t33.WITTS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a9080a5]\" id=\"form-field-field_a9080a5\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0a222c1 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a222c1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t34. CANT OOP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0a222c1]\" id=\"form-field-field_0a222c1\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_93515d6 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_93515d6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t34.1 FACIAL AXIS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_93515d6]\" id=\"form-field-field_93515d6\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_964f1e6 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_964f1e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t35. U1-NA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_964f1e6]\" id=\"form-field-field_964f1e6\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3aabc14 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3aabc14\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t36.IPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3aabc14]\" id=\"form-field-field_3aabc14\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1f99c56 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f99c56\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t37. L1-NB\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1f99c56]\" id=\"form-field-field_1f99c56\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_15aeb26 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_15aeb26\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t38. IMPA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_15aeb26]\" id=\"form-field-field_15aeb26\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ddd4cb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ddd4cb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t39. UPPER LIP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ddd4cb]\" id=\"form-field-field_3ddd4cb\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_40432a1 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_40432a1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t40. LOWER LIP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40432a1]\" id=\"form-field-field_40432a1\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_55436c5 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_55436c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t41. Otras observaciones rx perfil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_55436c5]\" id=\"form-field-field_55436c5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0c7da83 elementor-col-70\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0c7da83\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t41.1 Que observaciones rx perfil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0c7da83]\" id=\"form-field-field_0c7da83\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_5123c3e elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"An\u00e1lisis Facial\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_710878e elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_710878e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t42. Tipo de cara\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_710878e]\" id=\"form-field-field_710878e\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mesoprosopo (Mesofacial)\">Mesoprosopo (Mesofacial)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Leptoprosopo (Dolicofacial)\">Leptoprosopo (Dolicofacial)<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Euriprosopo (Braquifacial)\">Euriprosopo (Braquifacial)<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1d2a98d elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1d2a98d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t43. Asimetr\u00eda facial\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1d2a98d]\" id=\"form-field-field_1d2a98d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e8d7290 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e8d7290\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t43.1 En que tercio\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e8d7290]\" id=\"form-field-field_e8d7290\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Superior\">Superior<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Medio\">Medio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Inferior\">Inferior<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_420c9ed elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_420c9ed\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t43.2 Hacia que lado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_420c9ed]\" id=\"form-field-field_420c9ed\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha\">Derecha<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2b50b13 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2b50b13\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t44. Tipo de sonrisa\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2b50b13]\" id=\"form-field-field_2b50b13\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Papilar\">Papilar<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gingival\">Gingival<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Coronal\">Coronal<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_67f40f1 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_67f40f1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t45. Plano oclusal canteado\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_67f40f1]\" id=\"form-field-field_67f40f1\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_193cd36 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_193cd36\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t45.1 Hacia donde esta canteado el plano colusal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_193cd36]\" id=\"form-field-field_193cd36\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha\">Derecha<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8568eb5 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8568eb5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t46. Inserci\u00f3n frenillo labial superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8568eb5]\" id=\"form-field-field_8568eb5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mucosa\">Mucosa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gingival\">Gingival<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aberrante\">Aberrante<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1295042 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1295042\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t46.1  Inserci\u00f3n frenillo labial lateral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1295042]\" id=\"form-field-field_1295042\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mucosa\">Mucosa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gingival\">Gingival<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aberrante\">Aberrante<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ff7d26d elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ff7d26d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t46.2  Inserci\u00f3n frenillo labial inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ff7d26d]\" id=\"form-field-field_ff7d26d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mucosa\">Mucosa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Gingival\">Gingival<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aberrante\">Aberrante<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_707f412 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_707f412\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t46.3  Inserci\u00f3n frenillo lingual\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_707f412]\" id=\"form-field-field_707f412\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Mucosa\">Mucosa<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Corto\">Corto<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_81ed062 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_81ed062\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t47. Tipo de perfil\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_81ed062]\" id=\"form-field-field_81ed062\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Recto\">Recto<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Convexo\">Convexo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Concavo\">Concavo<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_dc336c8 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dc336c8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t48. Labios en reposo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_dc336c8]\" id=\"form-field-field_dc336c8\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Con contacto\">Con contacto<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Sin contacto\">Sin contacto<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6bef1c6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6bef1c6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t49. Posici\u00f3n labial superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6bef1c6]\" id=\"form-field-field_6bef1c6\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normoquelia\">Normoquelia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Proquelia\">Proquelia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Retroquelia\">Retroquelia<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_536c54d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_536c54d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t49.1 Posici\u00f3n labial inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_536c54d]\" id=\"form-field-field_536c54d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normoquelia\">Normoquelia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Proquelia\">Proquelia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Retroquelia\">Retroquelia<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3b5567f elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3b5567f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t50. Tonicidad labial superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3b5567f]\" id=\"form-field-field_3b5567f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normal\">Normal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hipertonia\">Hipertonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hipotonia\">Hipotonia<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ee86e45 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ee86e45\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t50.1 Tonicidad labial inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ee86e45]\" id=\"form-field-field_ee86e45\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normal\">Normal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hipertonia\">Hipertonia<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Hipotonia\">Hipotonia<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2ffbc12 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2ffbc12\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t51. Biprotrusion grave\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2ffbc12]\" id=\"form-field-field_2ffbc12\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1b48126 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1b48126\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t52. Labio y paladar hendido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1b48126]\" id=\"form-field-field_1b48126\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_31574f8 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_31574f8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t52.1 Donde labio y paladar hendido\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_31574f8]\" id=\"form-field-field_31574f8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b95e0f3 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b95e0f3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t53. Dismorfologia craneal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b95e0f3]\" id=\"form-field-field_b95e0f3\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7ecb820 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7ecb820\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t53.1 Donde dismorfologia craneal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7ecb820]\" id=\"form-field-field_7ecb820\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7e8d98d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7e8d98d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t54. Presenta asimetr\u00eda esquel\u00e9tica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7e8d98d]\" id=\"form-field-field_7e8d98d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3094e86 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3094e86\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t55. Paciente quirurgico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3094e86]\" id=\"form-field-field_3094e86\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d104b73 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d104b73\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t55.1 Por que paciente quirurgico\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d104b73]\" id=\"form-field-field_d104b73\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6c80c00 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"An\u00e1lisis Funcional\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0f58fad elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0f58fad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t56. H\u00e1bitos\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0f58fad]\" id=\"form-field-field_0f58fad\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-checkbox elementor-field-group elementor-column elementor-field-group-field_4021523 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4021523\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t56.1 Cuales h\u00e1bitos presenta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Onicofagia\" id=\"form-field-field_4021523-0\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-0\">Onicofagia<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Succi\u00f3n labial\" id=\"form-field-field_4021523-1\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-1\">Succi\u00f3n labial<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Respiraci\u00f3n oral\" id=\"form-field-field_4021523-2\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-2\">Respiraci\u00f3n oral<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Alteraci\u00f3n fon\u00e9tica\" id=\"form-field-field_4021523-3\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-3\">Alteraci\u00f3n fon\u00e9tica<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Succi\u00f3n digital\" id=\"form-field-field_4021523-4\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-4\">Succi\u00f3n digital<\/label><\/span><span class=\"elementor-field-option\"><input type=\"checkbox\" value=\"Fumador\" id=\"form-field-field_4021523-5\" name=\"form_fields[field_4021523][]\"> <label for=\"form-field-field_4021523-5\">Fumador<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_46b7aee elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_46b7aee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t57. Degluci\u00f3n at\u00edpica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_46b7aee]\" id=\"form-field-field_46b7aee\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No presenta\">No presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_434d48c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_434d48c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t57.1 Que tipo de degluci\u00f3n at\u00edpica\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_434d48c]\" id=\"form-field-field_434d48c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Empuje lingual simple\">Empuje lingual simple<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Empuje lingual complejo\">Empuje lingual complejo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Infantil\">Infantil<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1a2d544 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1a2d544\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t58. Bruxismo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1a2d544]\" id=\"form-field-field_1a2d544\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No presenta\">No presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7e214a8 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7e214a8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t58. 1 Que tipo de bruxismo\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7e214a8]\" id=\"form-field-field_7e214a8\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Nocturno\">Nocturno<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Diurno\">Diurno<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Combinado D y N\">Combinado D y N<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_03781af elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_03781af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t59. Desviaci\u00f3n mandibular\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_03781af]\" id=\"form-field-field_03781af\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No presenta\">No presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6b4523c elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6b4523c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t59.1 Hacia donde la desviaci\u00f3n mandibular\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6b4523c]\" id=\"form-field-field_6b4523c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha \">Derecha <\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0c2eda5 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0c2eda5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t59.2 Que tipo de desviacion\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0c2eda5]\" id=\"form-field-field_0c2eda5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Funcional\">Funcional<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Esqueletica\">Esqueletica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1048c68 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1048c68\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t60. Ruido ATM derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1048c68]\" id=\"form-field-field_1048c68\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_feb3acf elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_feb3acf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t60.1 Tipo de ruido ATM derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_feb3acf]\" id=\"form-field-field_feb3acf\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clicking\">Clicking<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pop\">Pop<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Crepitaci\u00f3n\">Crepitaci\u00f3n<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_067cc9d elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_067cc9d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t60.2 Localizacion ruido ATM derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_067cc9d]\" id=\"form-field-field_067cc9d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Apertura\">Apertura<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Intermedio\">Intermedio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cierre\">Cierre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Apertura y Cierre\">Apertura y Cierre<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2d87d2d elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2d87d2d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t61. Ruido ATM izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2d87d2d]\" id=\"form-field-field_2d87d2d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c2cd417 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c2cd417\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t61.1 Tipo de ruido ATM izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c2cd417]\" id=\"form-field-field_c2cd417\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clicking\">Clicking<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Pop\">Pop<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Crepitaci\u00f3n\">Crepitaci\u00f3n<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1ee67fe elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1ee67fe\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t61.2 Localizaci\u00f3n ruido ATM izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1ee67fe]\" id=\"form-field-field_1ee67fe\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Apertura\">Apertura<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Intermedio\">Intermedio<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cierre\">Cierre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Apertura y Cierre\">Apertura y Cierre<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a1f1760 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a1f1760\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t62. Apertura m\u00e1xima\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a1f1760]\" id=\"form-field-field_a1f1760\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"20 mm\">20 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"25 mm\">25 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"30 mm\">30 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"35 mm\">35 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"40 mm\">40 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"45 mm\">45 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"50 mm\">50 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"55 mm\">55 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"60 mm\">60 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"65 mm\">65 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"70 mm\">70 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5896b33 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5896b33\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t63. Dolor articular\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5896b33]\" id=\"form-field-field_5896b33\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_cd79e8f elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cd79e8f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t63.1 Localizaci\u00f3n del dolor articular\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_cd79e8f]\" id=\"form-field-field_cd79e8f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En reposo\">En reposo<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En apertura\">En apertura<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En cierre\">En cierre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En apertura y cierre\">En apertura y cierre<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En protrusiva\">En protrusiva<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"En lateralidad\">En lateralidad<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7b3bdfd elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7b3bdfd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t63.2 Lado del dolor articular\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7b3bdfd]\" id=\"form-field-field_7b3bdfd\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha\">Derecha<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha e izquierda\">Derecha e izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6053b7e elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"An\u00e1lisis Dental \" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4349338 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4349338\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t64. Tipo de dentici\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4349338]\" id=\"form-field-field_4349338\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Permanente\">Permanente<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Temporal\">Temporal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mixta\">Mixta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_93bf86c elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_93bf86c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t65. Relaci\u00f3n molar derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_93bf86c]\" id=\"form-field-field_93bf86c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Clase I\">Clase I<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase II\">Clase II<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase III\">Clase III<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0487be5 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0487be5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t65.1 Cuantos mm RM derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0487be5]\" id=\"form-field-field_0487be5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_30a9651 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_30a9651\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t65.2 Por que no aplica RM derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_30a9651]\" id=\"form-field-field_30a9651\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 16\">Ausencia dental del 16<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 46\">Ausencia dental del 46<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 16\">Destrucci\u00f3n coronal del 16<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 46\">Destrucci\u00f3n coronal del 46<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1c4fc3f elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c4fc3f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t66. Relaci\u00f3n molar izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1c4fc3f]\" id=\"form-field-field_1c4fc3f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Clase I\">Clase I<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase II\">Clase II<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase III\">Clase III<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7246e57 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7246e57\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t66.1 Cuantos mm RM izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7246e57]\" id=\"form-field-field_7246e57\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_dd260b6 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dd260b6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t66.2 Por que no aplica RM izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_dd260b6]\" id=\"form-field-field_dd260b6\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 26\">Ausencia dental del 26<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 36\">Ausencia dental del 36<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 26\">Destrucci\u00f3n coronal del 26<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 36\">Destrucci\u00f3n coronal del 36<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_b3725d3 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b3725d3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t67. Relaci\u00f3n canina derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_b3725d3]\" id=\"form-field-field_b3725d3\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Clase I\">Clase I<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase II\">Clase II<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase III\">Clase III<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2d0e130 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2d0e130\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t67.1 Cuantos mm RC derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2d0e130]\" id=\"form-field-field_2d0e130\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7463bfd elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7463bfd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t67.2 Por que no aplica RC derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7463bfd]\" id=\"form-field-field_7463bfd\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 13\">Ausencia dental del 13<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 43\">Ausencia dental del 43<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 13\">Destrucci\u00f3n coronal del 13<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 43\">Destrucci\u00f3n coronal del 43<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9a9af71 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9a9af71\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t68. Relaci\u00f3n canina izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9a9af71]\" id=\"form-field-field_9a9af71\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Clase I\">Clase I<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase II\">Clase II<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Clase III\">Clase III<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_45beecc elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_45beecc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t68.1 Cuantos mm RC izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_45beecc]\" id=\"form-field-field_45beecc\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_9798209 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9798209\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t68.2 Por que no aplica RC izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_9798209]\" id=\"form-field-field_9798209\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 23\">Ausencia dental del 23<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Ausencia dental del 33\">Ausencia dental del 33<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 23\">Destrucci\u00f3n coronal del 23<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Destrucci\u00f3n coronal del 33\">Destrucci\u00f3n coronal del 33<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0fc3b89 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0fc3b89\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t69. Overjet\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0fc3b89]\" id=\"form-field-field_0fc3b89\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normal\">Normal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Aumentado\">Aumentado<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Disminuido\">Disminuido<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_77e9adf elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_77e9adf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t69.1 Cuantos mm overjet\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_77e9adf]\" id=\"form-field-field_77e9adf\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a80f98b elementor-col-80\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a80f98b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70. Mordida cruzada overjet (si es si entonces diligenciar las medidas de cada diente)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a80f98b]\" id=\"form-field-field_a80f98b\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7d9acf2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7d9acf2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.1 OJ Diente 13\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7d9acf2]\" id=\"form-field-field_7d9acf2\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ac5ce1f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac5ce1f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.2 OJ Diente 12\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ac5ce1f]\" id=\"form-field-field_ac5ce1f\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6318e7e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6318e7e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.3 OJ Diente 11\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6318e7e]\" id=\"form-field-field_6318e7e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_12d133b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12d133b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.4 OJ Diente 21\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_12d133b]\" id=\"form-field-field_12d133b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_89900bf elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_89900bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.5 OJ Diente 22\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_89900bf]\" id=\"form-field-field_89900bf\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3874ddc elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3874ddc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t70.6 OJ Diente 23\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3874ddc]\" id=\"form-field-field_3874ddc\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_6165eb3 elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6165eb3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t71. Mordida profunda del 100%\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_6165eb3]\" id=\"form-field-field_6165eb3\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No\">No<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si\">Si<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_201f940 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_201f940\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t72. Overbite\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_201f940]\" id=\"form-field-field_201f940\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Normal\">Normal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mordida abierta\">Mordida abierta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Mordida profunda\">Mordida profunda<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Borde a borde\">Borde a borde<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_43b9901 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_43b9901\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t72.1 Cuantos mm overbite\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_43b9901]\" id=\"form-field-field_43b9901\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_54b588a elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_54b588a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t73. Linea media dental superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_54b588a]\" id=\"form-field-field_54b588a\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Centrada\">Centrada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Desviada\">Desviada<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4b38608 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4b38608\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t73.1 Cuantos mm desviada LMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4b38608]\" id=\"form-field-field_4b38608\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ef3edde elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ef3edde\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t73.2 Hacia donde desviada LMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ef3edde]\" id=\"form-field-field_ef3edde\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha\">Derecha<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fb0a009 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb0a009\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t74. Linea media dental inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fb0a009]\" id=\"form-field-field_fb0a009\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Centrada\">Centrada<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Desviada\">Desviada<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_269f870 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_269f870\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t74.1 Cuantos mm desviada LMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_269f870]\" id=\"form-field-field_269f870\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_87cd7ab elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_87cd7ab\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t74.2 Hacia donde desviada LMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_87cd7ab]\" id=\"form-field-field_87cd7ab\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"-\">-<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Derecha\">Derecha<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Izquierda\">Izquierda<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_0c99173 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0c99173\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t75. Morfolog\u00eda de arco superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_0c99173]\" id=\"form-field-field_0c99173\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Ovoidal\">Ovoidal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Triangular\">Triangular<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuadrado\">Cuadrado<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e246150 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e246150\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t75.1 Morfolog\u00eda de arco inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e246150]\" id=\"form-field-field_e246150\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Ovoidal\">Ovoidal<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Triangular\">Triangular<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Cuadrado\">Cuadrado<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_96a0c8d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_96a0c8d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t76. Mordida cruzada anterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_96a0c8d]\" id=\"form-field-field_96a0c8d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_78c510d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_78c510d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t76.1 Donde presenta mordida cruzada anterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_78c510d]\" id=\"form-field-field_78c510d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_cf53f06 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cf53f06\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t77. Mordida cruzada posterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_cf53f06]\" id=\"form-field-field_cf53f06\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_65f0302 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_65f0302\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t77.1 Donde presenta mordida cruzada posterior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_65f0302]\" id=\"form-field-field_65f0302\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_da086fb elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_da086fb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.Mordida cruzada post hacia palatino (llenar si presenta)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_da086fb]\" id=\"form-field-field_da086fb\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b25df68 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b25df68\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.1 Diente 17 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b25df68]\" id=\"form-field-field_b25df68\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e0db643 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e0db643\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.2 Diente 16 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e0db643]\" id=\"form-field-field_e0db643\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_69ad7d4 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_69ad7d4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.3 Diente 15 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_69ad7d4]\" id=\"form-field-field_69ad7d4\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6b8477c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6b8477c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.4 Diente 14 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6b8477c]\" id=\"form-field-field_6b8477c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6a9f20d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6a9f20d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.5 Diente 24 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6a9f20d]\" id=\"form-field-field_6a9f20d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_452dfbb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_452dfbb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.6 Diente 25 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_452dfbb]\" id=\"form-field-field_452dfbb\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5565be9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5565be9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.7 Diente 26 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5565be9]\" id=\"form-field-field_5565be9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_85acf92 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_85acf92\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t78.8 Diente 27 MCPP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_85acf92]\" id=\"form-field-field_85acf92\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4a8e970 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4a8e970\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.Mordida cruzada post hacia vertibular (llenar si presenta)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4a8e970]\" id=\"form-field-field_4a8e970\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_71f9430 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_71f9430\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.1 Diente 17 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_71f9430]\" id=\"form-field-field_71f9430\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_25ed432 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_25ed432\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.2 Diente 16 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_25ed432]\" id=\"form-field-field_25ed432\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_348b78c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_348b78c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.3 Diente 15 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_348b78c]\" id=\"form-field-field_348b78c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cc70c9b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cc70c9b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.4 Diente 14 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cc70c9b]\" id=\"form-field-field_cc70c9b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_02a504d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_02a504d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.5 Diente 24 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_02a504d]\" id=\"form-field-field_02a504d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b5f831c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b5f831c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.6 Diente 25 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b5f831c]\" id=\"form-field-field_b5f831c\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_65f073a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_65f073a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.7 Diente 26 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_65f073a]\" id=\"form-field-field_65f073a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9050f3a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9050f3a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t79.8 Diente 27 MCPV\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9050f3a]\" id=\"form-field-field_9050f3a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_7bc0ebf elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7bc0ebf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t80. Profundidad curva de spee derecha\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_7bc0ebf]\" id=\"form-field-field_7bc0ebf\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_5de050c elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5de050c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t80.1 Profundidad curva de spee izquierda\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_5de050c]\" id=\"form-field-field_5de050c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0\">0<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1\">1<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2\">2<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3\">3<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4\">4<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5\">5<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_57a9e79 elementor-col-80\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_57a9e79\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81. Mordida abierta anterior (medir cada diente si es > a 0mm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_57a9e79]\" id=\"form-field-field_57a9e79\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f23be55 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f23be55\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.1 Diente 13 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f23be55]\" id=\"form-field-field_f23be55\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4488b75 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4488b75\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.2 Diente 12 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4488b75]\" id=\"form-field-field_4488b75\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b2216d5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b2216d5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.3 Diente 11 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b2216d5]\" id=\"form-field-field_b2216d5\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_dfeef25 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dfeef25\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.4 Diente 21 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_dfeef25]\" id=\"form-field-field_dfeef25\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d4b7477 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d4b7477\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.5 Diente 22 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d4b7477]\" id=\"form-field-field_d4b7477\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d5dacbb elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d5dacbb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t81.6 Diente 23 MAA\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d5dacbb]\" id=\"form-field-field_d5dacbb\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c724d54 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c724d54\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82. Mordida abierta posterior (medir cada diente si es > a 0mm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c724d54]\" id=\"form-field-field_c724d54\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_8780430 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8780430\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.1 Diente 17 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_8780430]\" id=\"form-field-field_8780430\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6d27362 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d27362\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.2 Diente 16 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6d27362]\" id=\"form-field-field_6d27362\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c600725 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c600725\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.3 Diente 15 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c600725]\" id=\"form-field-field_c600725\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fde4c4a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fde4c4a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.4 Diente 14 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fde4c4a]\" id=\"form-field-field_fde4c4a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_72b6da9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_72b6da9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.5 Diente 24 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_72b6da9]\" id=\"form-field-field_72b6da9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_df4504a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_df4504a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.6 Diente 25 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_df4504a]\" id=\"form-field-field_df4504a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4ab4fbc elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4ab4fbc\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.7 Diente 26 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4ab4fbc]\" id=\"form-field-field_4ab4fbc\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7dc825d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7dc825d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t82.8 Diente 27 MAP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7dc825d]\" id=\"form-field-field_7dc825d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e58296d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e58296d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t83. Dientes ausentes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e58296d]\" id=\"form-field-field_e58296d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Escribir dientes reparados por comas\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1d05f1d elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1d05f1d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t83.1 Dientes en erupci\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1d05f1d]\" id=\"form-field-field_1d05f1d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Escribir dientes reparados por comas\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_fa5dfc8 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fa5dfc8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t84. Api\u00f1amiento 1er cuadrante\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_fa5dfc8]\" id=\"form-field-field_fa5dfc8\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_8db2db3 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8db2db3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t84.1 Api\u00f1amiento 2do cuadrante\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_8db2db3]\" id=\"form-field-field_8db2db3\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_804c37e elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_804c37e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t84.2 Api\u00f1amiento 3er cuadrante\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_804c37e]\" id=\"form-field-field_804c37e\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_4e7fda8 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4e7fda8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t84.3 Api\u00f1amiento 4to cuadrante\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_4e7fda8]\" id=\"form-field-field_4e7fda8\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"0 mm\">0 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"1 mm\">1 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"2 mm\">2 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"3 mm\">3 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"4 mm\">4 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"5 mm\">5 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"6 mm\">6 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"7 mm\">7 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"8 mm\">8 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"9 mm\">9 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"10 mm\">10 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"11 mm\">11 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"12 mm\">12 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"13 mm\">13 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"14 mm\">14 mm<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"15 mm\">15 mm<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_96015da elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_96015da\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t85. Presenta espaciamiento maxilar superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_96015da]\" id=\"form-field-field_96015da\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ba377ca elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ba377ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t85.1 Donde presenta espaciamiento superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ba377ca]\" id=\"form-field-field_ba377ca\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_04c9d56 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_04c9d56\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t85.2 Cuantos dts presentan espaciamiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_04c9d56]\" id=\"form-field-field_04c9d56\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_2b77f61 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2b77f61\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t86. Presenta espaciamiento maxilar inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_2b77f61]\" id=\"form-field-field_2b77f61\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fc9e00b elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc9e00b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t86.1 Donde presenta espaciamiento inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fc9e00b]\" id=\"form-field-field_fc9e00b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a13e7ee elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a13e7ee\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t86.2 Cuantos dts presentan espaciamiento\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a13e7ee]\" id=\"form-field-field_a13e7ee\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_74c4bc6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_74c4bc6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t87. Presenta espaciamiento entre incisivos centrales superiores\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_74c4bc6]\" id=\"form-field-field_74c4bc6\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_43fc7af elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_43fc7af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t87.1 Cuanto espaciamiento (en mm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_43fc7af]\" id=\"form-field-field_43fc7af\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_89860ef elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_89860ef\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t88. Presenta transposici\u00f3n dental\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_89860ef]\" id=\"form-field-field_89860ef\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_75286af elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_75286af\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t88.1 Donde presenta transposici\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_75286af]\" id=\"form-field-field_75286af\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3d33918 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3d33918\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t88.2 Cuantos presentan transposici\u00f3n\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3d33918]\" id=\"form-field-field_3d33918\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_79360f1 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_79360f1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t89. Presenta microdoncia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_79360f1]\" id=\"form-field-field_79360f1\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_0a01ce8 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0a01ce8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t89.1 Donde presenta microdoncia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_0a01ce8]\" id=\"form-field-field_0a01ce8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ef7e70b elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ef7e70b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t89.2 Cuantos presentan microdoncia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ef7e70b]\" id=\"form-field-field_ef7e70b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e4c6d7c elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e4c6d7c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t90. Perimetro de arco superior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e4c6d7c]\" id=\"form-field-field_e4c6d7c\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Aplica\">Si Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9473b26 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9473b26\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t90.1 Por que no aplica PAS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9473b26]\" id=\"form-field-field_9473b26\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_dc03155 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dc03155\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t90.2 Medida (mm) PAS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_dc03155]\" id=\"form-field-field_dc03155\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_035cbe7 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_035cbe7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t91. Perimetro de arco inferior\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_035cbe7]\" id=\"form-field-field_035cbe7\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Aplica\">No Aplica<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Aplica\">Si Aplica<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6055ea7 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6055ea7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t91.1 Por que no aplica PAI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6055ea7]\" id=\"form-field-field_6055ea7\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e89c071 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e89c071\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t91.2 Medida (mm) PAI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e89c071]\" id=\"form-field-field_e89c071\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f8855a3 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f8855a3\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t92. Distancia Intermolar sup\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f8855a3]\" id=\"form-field-field_f8855a3\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_12061a1 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_12061a1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t92.1 Distancia Intercanina sup\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_12061a1]\" id=\"form-field-field_12061a1\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a03fb49 elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a03fb49\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t92.2 Distancia Intermolar inf\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a03fb49]\" id=\"form-field-field_a03fb49\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e79e32a elementor-col-25\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e79e32a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t92.3 Distancia Intercanina inf\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e79e32a]\" id=\"form-field-field_e79e32a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_84a1196 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_84a1196\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93. Ancho mesodistal maxilar superior (diligenciar cada uno en mm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_84a1196]\" id=\"form-field-field_84a1196\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_533d5dd elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_533d5dd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.1 Diente 16 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_533d5dd]\" id=\"form-field-field_533d5dd\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a6855ce elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a6855ce\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.2 Diente 15 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a6855ce]\" id=\"form-field-field_a6855ce\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6d34353 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6d34353\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.3 Diente 14 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6d34353]\" id=\"form-field-field_6d34353\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_82d2ef9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_82d2ef9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.4 Diente 13 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_82d2ef9]\" id=\"form-field-field_82d2ef9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_da0a3ad elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_da0a3ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.5 Diente 12 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_da0a3ad]\" id=\"form-field-field_da0a3ad\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_07c6f6b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_07c6f6b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.6 Diente 11 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_07c6f6b]\" id=\"form-field-field_07c6f6b\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5050fd1 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5050fd1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.7 Diente 21 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5050fd1]\" id=\"form-field-field_5050fd1\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e08fb16 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e08fb16\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.8 Diente 22 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e08fb16]\" id=\"form-field-field_e08fb16\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a5c8242 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a5c8242\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.9 Diente 23 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a5c8242]\" id=\"form-field-field_a5c8242\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b87561f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b87561f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.10 Diente 24 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b87561f]\" id=\"form-field-field_b87561f\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_922c891 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_922c891\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.11 Diente 25 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_922c891]\" id=\"form-field-field_922c891\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_eecd438 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_eecd438\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t93.12 Diente 26 AMDS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_eecd438]\" id=\"form-field-field_eecd438\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_533ae88 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_533ae88\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94. Ancho mesodistal maxilar inferior (diligenciar cada uno en mm)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_533ae88]\" id=\"form-field-field_533ae88\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"\"><\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_cab9b24 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_cab9b24\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.1 Diente 36 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_cab9b24]\" id=\"form-field-field_cab9b24\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3b586ad elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3b586ad\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.2 Diente 35 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3b586ad]\" id=\"form-field-field_3b586ad\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d94062e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d94062e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.3 Diente 34 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d94062e]\" id=\"form-field-field_d94062e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_100a4be elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_100a4be\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.4 Diente 33 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_100a4be]\" id=\"form-field-field_100a4be\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a17470d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a17470d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.5 Diente 32 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a17470d]\" id=\"form-field-field_a17470d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c0780ae elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c0780ae\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.6 Diente 31 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c0780ae]\" id=\"form-field-field_c0780ae\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_1d0fbef elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1d0fbef\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.7 Diente 41 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_1d0fbef]\" id=\"form-field-field_1d0fbef\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2baf99e elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2baf99e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.8 Diente 42 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2baf99e]\" id=\"form-field-field_2baf99e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fc232b9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fc232b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.9 Diente 43 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fc232b9]\" id=\"form-field-field_fc232b9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_dcc9481 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_dcc9481\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.10 Diente 44 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_dcc9481]\" id=\"form-field-field_dcc9481\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_5718ece elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5718ece\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.11 Diente 45 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_5718ece]\" id=\"form-field-field_5718ece\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_108a733 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_108a733\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t94.12 Diente 46 AMDI\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_108a733]\" id=\"form-field-field_108a733\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_efe3d39 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Estetica Dental\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_3da5fbf elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3da5fbf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t95. Biotipo periodontal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_3da5fbf]\" id=\"form-field-field_3da5fbf\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"Grueso\">Grueso<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Delgado\">Delgado<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1c5ba1f elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c5ba1f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t96. Agrandamiento gingival\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1c5ba1f]\" id=\"form-field-field_1c5ba1f\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_957d2a5 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_957d2a5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t96.1 Donde presenta agrandamiento gingival\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_957d2a5]\" id=\"form-field-field_957d2a5\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_1e77820 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1e77820\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t97. Recesi\u00f3n gingival\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_1e77820]\" id=\"form-field-field_1e77820\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_3ede89e elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3ede89e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t97.1 Donde presenta recesi\u00f3n gingival\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_3ede89e]\" id=\"form-field-field_3ede89e\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_ce29c3d elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ce29c3d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t98. Capuchon pericoronario\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_ce29c3d]\" id=\"form-field-field_ce29c3d\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_219ff3a elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_219ff3a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t98.1 Donde presenta capuchon pericoronario\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_219ff3a]\" id=\"form-field-field_219ff3a\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_faeb5ab elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_faeb5ab\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t99. Triangulos negros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_faeb5ab]\" id=\"form-field-field_faeb5ab\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e6bfae9 elementor-col-60\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e6bfae9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t99.1 Donde presenta triangulos negros\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e6bfae9]\" id=\"form-field-field_e6bfae9\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_e059a47 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e059a47\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t100. Defectos del esmalte\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_e059a47]\" id=\"form-field-field_e059a47\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_76994f8 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_76994f8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t100.1 Cual defecto presenta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_76994f8]\" id=\"form-field-field_76994f8\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"Fluoorosis, perlas, fracturas\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_2f7f917 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2f7f917\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t100.2 En que dientes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_2f7f917]\" id=\"form-field-field_2f7f917\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_95541c5 elementor-col-40\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_95541c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t101. Anmalia de morfologia dental\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_95541c5]\" id=\"form-field-field_95541c5\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Presenta\">No Presenta<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Presenta\">Si Presenta<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c51086d elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c51086d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t101.1 Cual anomalia\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c51086d]\" id=\"form-field-field_c51086d\" class=\"elementor-field elementor-size-xs  elementor-field-textual\" placeholder=\"microdoncis, fusion, geminasion\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ada45bf elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ada45bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t101.2 Cuantos dientes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ada45bf]\" id=\"form-field-field_ada45bf\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_a3cc107 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a3cc107\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t102. Requiere nivelacion de punto cenit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_a3cc107]\" id=\"form-field-field_a3cc107\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Requiere\">No Requiere<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Requiere\">Si Requiere<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a8c4abd elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a8c4abd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t102.1 Donde requiere la nivelaci\u00f3n de punto cenit\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a8c4abd]\" id=\"form-field-field_a8c4abd\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_c1471e6 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c1471e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t103. Requiere reconstruccion de bordes incisales\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_c1471e6]\" id=\"form-field-field_c1471e6\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Requiere\">No Requiere<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Requiere\">Si Requiere<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_443c156 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_443c156\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t103.1 Donde requiere reconstruccion de bordes incisales\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_443c156]\" id=\"form-field-field_443c156\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-select elementor-field-group elementor-column elementor-field-group-field_47cbf5e elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_47cbf5e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t104. Espacios que requieran rehabilitacion oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field elementor-select-wrapper remove-before \">\n\t\t\t<div class=\"select-caret-down-wrapper\">\n\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-caret-down\"><\/i>\t\t\t<\/div>\n\t\t\t<select name=\"form_fields[field_47cbf5e]\" id=\"form-field-field_47cbf5e\" class=\"elementor-field-textual elementor-size-xs\">\n\t\t\t\t\t\t\t\t\t<option value=\"No Requiere\">No Requiere<\/option>\n\t\t\t\t\t\t\t\t\t<option value=\"Si Requiere\">Si Requiere<\/option>\n\t\t\t\t\t\t\t<\/select>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9fb4861 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9fb4861\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t104.1 Donde requiere rehabilitacion oral\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9fb4861]\" id=\"form-field-field_9fb4861\" class=\"elementor-field elementor-size-xs  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Enviar<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Please complete all fields and avoid skipping information.<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"class_list":["post-5107","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>HC ERASO 2025 - Javier Eraso Ortodoncia<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/javiererasoortodoncia.com\/en\/hc-eraso-2025\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"HC ERASO 2025 - Javier Eraso Ortodoncia\" \/>\n<meta property=\"og:description\" content=\"Por favor diligencia todos los campos y evita saltar informaci\u00f3n.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/javiererasoortodoncia.com\/en\/hc-eraso-2025\/\" \/>\n<meta property=\"og:site_name\" content=\"Javier Eraso Ortodoncia\" \/>\n<meta property=\"article:modified_time\" content=\"2025-10-22T11:18:35+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/javiererasoortodoncia.com\/wp-content\/uploads\/2024\/04\/LOGO-HC-DIGITAL.003-e1712333655200.png\" \/>\n\t<meta property=\"og:image:width\" content=\"1488\" \/>\n\t<meta property=\"og:image:height\" content=\"406\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"11 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/javiererasoortodoncia.com\\\/hc-eraso-2025\\\/\",\"url\":\"https:\\\/\\\/javiererasoortodoncia.com\\\/hc-eraso-2025\\\/\",\"name\":\"HC ERASO 2025 - 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