{"id":329,"date":"2022-10-03T23:53:16","date_gmt":"2022-10-03T23:53:16","guid":{"rendered":"http:\/\/test.pesgweb.com\/?page_id=329"},"modified":"2022-10-03T23:55:04","modified_gmt":"2022-10-03T23:55:04","slug":"referral","status":"publish","type":"page","link":"https:\/\/pesgweb.com\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"329\" class=\"elementor elementor-329\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-285e3d3 elementor-section-height-min-height elementor-section-boxed elementor-section-height-default elementor-section-items-middle\" data-id=\"285e3d3\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-1ada498\" data-id=\"1ada498\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-39da5e1 elementor-widget elementor-widget-shortcode\" data-id=\"39da5e1\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\n<script>\n\njQuery('#submitter_button').click(function () {\n    var company_name = jQuery('#company_name').val();\n    var first_name = jQuery('#first_name').val();\n    var last_name = jQuery('#last_name').val();\n    var main_phone = jQuery('#main_phone').val();\n    var email_address = jQuery('#email_address').val();\n\n    const array = [\n        company_name,\n        first_name,\n        last_name,\n        main_phone,\n        email_address\n    ]\n    const emptyItems = array.some((item) => item === '')\n\n    if (!emptyItems) {\n        $(\"#collapseTwo\").collapse(\"show\");\n    } \n\n});\n\njQuery('#claimant_button').click(function () {\n    var claimant_first_name = jQuery('#claimant_first_name').val();\n    var claimant_last_name = jQuery('#claimant_last_name').val();\n    var claimant_date_of_birth = jQuery('#claimant_date_of_birth').val();\n    var claimant_home_phone = jQuery('#claimant_home_phone').val();\n    var claimant_address_1 = jQuery('#claimant_address_1').val();\n    var claimant_city = jQuery('#claimant_city').val();\n    var claimant_state = jQuery('#claimant_state').val();\n    var claimant_zip = jQuery('#claimant_zip').val();\n\n    const array = [\n        claimant_first_name,\n        claimant_last_name,\n        claimant_date_of_birth,\n        claimant_home_phone,\n        claimant_address_1,\n        claimant_city,\n        claimant_state,\n        claimant_zip,\n    ]\n    const emptyItems = array.some((item) => item === '')\n\n    if (!emptyItems) {\n        $(\"#collapseThree\").collapse(\"show\");\n    } \n\n});\n\njQuery('#employee__button').click(function () {\n    var employee_date_of_injury = jQuery('#employee_date_of_injury').val();\n\n    const array = [\n        employee_date_of_injury,\n    ]\n    const emptyItems = array.some((item) => item === '')\n\n    if (!emptyItems) {\n        $(\"#collapsefour\").collapse(\"show\");\n    } \n});\n\njQuery('#ref_doctor_Button').click(function () {\n    var ref_doctor_first_name = jQuery('#ref_doctor_first_name').val();\n    var ref_doctor_last_name = jQuery('#ref_doctor_last_name').val();\n    var ref_doctor_surgery_date = jQuery('#ref_doctor_surgery_date').val();\n    var ref_doctor_follow_up_md = jQuery('#ref_doctor_follow_up_md').val();\n\n    const array = [\n        ref_doctor_first_name,\n        ref_doctor_last_name,\n        ref_doctor_surgery_date,\n        ref_doctor_follow_up_md\n    ]\n    const emptyItems = array.some((item) => item === '')\n\n    if (!emptyItems) {\n        $(\"#collapsefive\").collapse(\"show\");\n    } \n});\njQuery('#btnSendfile').click(function () {\n    $(\"#collapsesix\").collapse(\"show\");\n});\n\n\n    jQuery(document).ready(function() {\n        console.log(\"ESTAMOSSSSSSSSSSSSSSSSS EN EL READYYYYYYYYYYYYY\");\n        \n        var username = \"\";\n        jQuery('#wp-submit').click(function() {\n\n            \/\/Start code added by Eleizer\n\n            \/* Validate Inputs requieremets *\/\n                var company_name = jQuery('#company_name').val();\n                var first_name = jQuery('#first_name').val();\n                var last_name = jQuery('#last_name').val();\n                var main_phone = jQuery('#main_phone').val();\n                var email_address = jQuery('#email_address').val();\n                \n                const array = [\n                    company_name,\n                    first_name ,\n                    last_name,\n                    main_phone,\n                    email_address\n                ]\n                const emptyItems = array.some((item) => item === '')\n                \n                if(emptyItems){\n                    document.getElementById(\"error_submitt\").style.display = 'block';\n                    return;\n                } \n                document.getElementById(\"error_submitt\").style.display = 'none';\n             \/* End Validate Inputs requieremets*\/\n\n             \/\/ End code added by Eleizer\n\n\n            console.log(\"Calling button with is =  #wp-submit:=>>\");\n\n            jQuery(\"#referralform\").validate({\n                submitHandler: function(form) {\n                    \n                    \/***********************Array for Submitted******************************** *\/\n                    var submitterData = {};\n                   \n                    \/\/ Add random id current User\n                    submitterData.rand_id_user = \"095ae4268ddb176a\"; \n                                           \n                    \/******************************************************** *\/\n                    \/**                  Submiter                             *\/\n                    \/******************************************************** *\/\n\n                    \/\/GET DATA FORM \n                    var company_name = jQuery('#company_name').val();\n                    var first_name = jQuery('#first_name').val();\n                    var last_name = jQuery('#last_name').val();\n                    var main_phone = jQuery('#main_phone').val();\n                    var ext = jQuery('#ext').val();\n                    var fax = jQuery('#fax').val();\n                    var email_address = jQuery('#email_address').val();\n\n                    \/\/ ADD IN SUBMITTER DATA\n                    submitterData.company_name = company_name;\n                    submitterData.first_name = first_name;\n                    submitterData.last_name = last_name;\n                    submitterData.main_phone = main_phone;\n                    submitterData.ext = ext;\n                    submitterData.fax = fax;\n                    submitterData.email_address = email_address;\n\n                    \/******************************************************** *\/\n                    \/**                  Claimant                             *\/\n                    \/******************************************************** *\/\n                    \n                    \/\/GET DATA FORM \n                    var claimant_request = getRequestSelectedOptions();\n                    var claimant_first_name = jQuery('#claimant_first_name').val();\n                    var claimant_last_name = jQuery('#claimant_last_name').val();\n                    var claimant_claimant_number = jQuery('#claimant_claimant_number').val();\n                    var claimant_date_of_injury = jQuery('#claimant_date_of_injury').val();\n                    var claimant_icd_code = jQuery('#claimant_icd_code').val();\n                    var claimant_describe = jQuery('#claimant_describe').val();\n                    var claimant_working = getWorkingYesNo();\n                    var claimant_occupation = jQuery('#claimant_occupation').val();\n                    var claimant_date_of_birth = jQuery('#claimant_date_of_birth').val();\n                    var claimant_gender = getGenderMaleFemale();\n                    var claimant_home_phone = jQuery('#claimant_home_phone').val();\n                    var claimant_cell_phone = jQuery('#claimant_cell_phone').val();\n                    var claimant_work_phone = jQuery('#claimant_work_phone').val();\n                    var claimant_ext = jQuery('#claimant_ext').val();\n                    var claimant_alternate_phone = jQuery('#claimant_alternate_phone').val();\n                    var claimant_alt_phone_description = jQuery('#claimant_alt_phone_description').val();\n                    var claimant_email_adress = jQuery('#claimant_email_adress').val();\n                    var claimant_address_1 = jQuery('#claimant_address_1').val();\n                    var claimant_address_2 = jQuery('#claimant_address_2').val();\n                    var claimant_city = jQuery('#claimant_city').val();\n                    var claimant_state = jQuery('#claimant_state').val();\n                    var claimant_zip = jQuery('#claimant_zip').val();\n                    var claimant_preferred_language = jQuery('#claimant_preferred_language').val();\n                  \n                    \/\/ ADD IN SUBMITTER DATA\n                    submitterData.claimant_request = claimant_request;\n                    submitterData.claimant_first_name = claimant_first_name ;\n                    submitterData.claimant_last_name = claimant_last_name;\n                    submitterData.claimant_claimant_number = claimant_claimant_number\n                    submitterData.claimant_date_of_injury = claimant_date_of_injury;\n                    submitterData.claimant_icd_code = claimant_icd_code;\n                    submitterData.claimant_describe = claimant_describe;\n                    submitterData.claimant_working = getWorkingYesNo();\n                    submitterData.claimant_occupation = claimant_occupation;\n                    submitterData.claimant_date_of_birth = claimant_date_of_birth;\n                    submitterData.claimant_gender = getGenderMaleFemale();\n                    submitterData.claimant_home_phone = claimant_home_phone;\n                    submitterData.claimant_cell_phone = claimant_cell_phone;\n                    submitterData.claimant_work_phone = claimant_work_phone;\n                    submitterData.claimant_ext = claimant_ext;\n                    submitterData.claimant_alternate_phone = claimant_alternate_phone;\n                    submitterData.claimant_alt_phone_description = claimant_alt_phone_description;\n                    submitterData.claimant_email_adress = claimant_email_adress;\n                    submitterData.claimant_address_1 = claimant_address_1;\n                    submitterData.claimant_address_2 = claimant_address_2;\n                    submitterData.claimant_city = claimant_city;\n                    submitterData.claimant_state = claimant_state;\n                    submitterData.claimant_zip = claimant_zip;\n                    submitterData.claimant_preferred_language = claimant_preferred_language;\n\n                    \/******************************************************** *\/\n                    \/**                  Employee                             *\/\n                    \/******************************************************** *\/\n                    \n                    \/\/GET DATA FORM \n                    var employee_company = jQuery('#employee_company').val();\n                    var employee_phone_number = jQuery('#employee_phone_number').val();\n                    var employee_contact = jQuery('#employee_contact').val();\n                    var employee_address1 = jQuery('#employee_address1').val();\n                    var employee_address2 = jQuery('#employee_address2').val();\n                    var employee_city = jQuery('#employee_city').val();\n                    var employee_state = jQuery('#employee_state').val();\n                    var employee_zip = jQuery('#employee_zip').val();\n                    var employee_working_hours = getWorkingHours();\n                    var employee_date_of_injury = jQuery('#employee_date_of_injury').val();\n\n                    \/\/ ADD IN SUBMITTER DATA\n                    submitterData.employee_company = employee_company;\n                    submitterData.employee_phone_number = employee_phone_number;\n                    submitterData.employee_contact = employee_contact;\n                    submitterData.employee_address1 = employee_address1;\n                    submitterData.employee_address2 = employee_address2;\n                    submitterData.employee_city = employee_city;\n                    submitterData.employee_state = employee_state;\n                    submitterData.employee_zip = employee_zip;\n                    submitterData.employee_working_hours = getWorkingHours();\n                    submitterData.employee_date_of_injury = employee_date_of_injury;\n\n                    \/******************************************************** *\/\n                    \/**                  Referring Doctor                             *\/\n                    \/******************************************************** *\/\n                    \n                    \/\/GET DATA FORM \n                    var ref_doctor_first_name = jQuery('#ref_doctor_first_name').val();\n                    var ref_doctor_last_name = jQuery('#ref_doctor_last_name').val();\n                    var ref_doctor_practice_name = jQuery('#ref_doctor_practice_name').val();\n                    var ref_doctor_phone_number = jQuery('#ref_doctor_phone_number').val();\n                    var ref_doctor_email_adress = jQuery('#ref_doctor_email_adress').val();\n                    var ref_doctor_fax = jQuery('#ref_doctor_fax').val();\n                    var ref_doctor_adress_1 = jQuery('#ref_doctor_adress_1').val();\n                    var ref_doctor_adress_2 = jQuery('#ref_doctor_adress_2').val();\n                    var ref_doctor_city = jQuery('#ref_doctor_city').val();\n                    var ref_doctor_state = jQuery('#ref_doctor_state').val();\n                    var ref_doctor_zip = jQuery('#ref_doctor_zip').val();\n                    var ref_doctor_patient_have_surgery_1 = getRefDoctorPatientHaveSurgery_1();\/\/jQuery('#').val();\n                    var ref_doctor_surgery_date = jQuery('#ref_doctor_surgery_date').val();\n                    var ref_doctor_dx = jQuery('#ref_doctor_dx').val();\n                    var ref_doctor_body_parts = jQuery('#ref_doctor_body_parts').val();\n                    var ref_doctor_auth_visits = jQuery('#ref_doctor_auth_visits').val();\n                    var ref_doctor_freq_duration = jQuery('#ref_doctor_freq_duration').val();\n                    var ref_doctor_script = getRefDoctorScript();\n                    var ref_doctor_follow_up_md = jQuery('#ref_doctor_follow_up_md').val();\n                    \n                    \/\/ ADD IN SUBMITTER DATA\n                    submitterData.ref_doctor_first_name = ref_doctor_first_name;\n                    submitterData.ref_doctor_last_name = ref_doctor_last_name;\n                    submitterData.ref_doctor_practice_name = ref_doctor_practice_name;\n                    submitterData.ref_doctor_phone_number = ref_doctor_phone_number;\n                    submitterData.ref_doctor_email_adress = ref_doctor_email_adress;\n                    submitterData.ref_doctor_fax = ref_doctor_fax;\n                    submitterData.ref_doctor_adress_1 = ref_doctor_adress_1;\n                    submitterData.ref_doctor_adress_2 = ref_doctor_adress_2;\n                    submitterData.ref_doctor_city = ref_doctor_city;\n                    submitterData.ref_doctor_state = ref_doctor_state;\n                    submitterData.ref_doctor_zip = ref_doctor_zip;\n                    submitterData.ref_doctor_patient_have_surgery_1 = getRefDoctorPatientHaveSurgery_1();\n                    submitterData.ref_doctor_surgery_date = ref_doctor_surgery_date;\n                    submitterData.ref_doctor_dx = ref_doctor_dx;\n                    submitterData.ref_doctor_body_parts = ref_doctor_body_parts;\n                    submitterData.ref_doctor_auth_visits = ref_doctor_auth_visits;\n                    submitterData.ref_doctor_freq_duration = ref_doctor_freq_duration;\n                    submitterData.ref_doctor_script = getRefDoctorScript();\n                    submitterData.ref_doctor_follow_up_md = ref_doctor_follow_up_md;\n\n\n                    \/******************************************************** *\/\n                    \/**                 Special Instructions                     *\/\n                    \/******************************************************** *\/\n\n                    \/\/GET DATA FORM \n                    var special_instructions = jQuery('#special_instructions').val();\n                    \n                    \/\/ ADD IN SUBMITTER DATA\n                    submitterData.special_instructions = special_instructions;\n\n\n                    \/******************************************************** *\/\n                    \/**                      Attachment                       *\/\n                    \/******************************************************** *\/\n\n                    \/\/GET DATA FORM \n                    var attachments_file = jQuery('#attachments_file').val();                 \n\n\n\n\n\n \/***********************************************END WRITE PDF******************************************************** *\/\n\n                    console.log(submitterData);\n\n                    var apiUrl = 'https:\/\/pesgweb.com\/wp-json\/saved\/data_in_server';\n                    var queryString = jQuery.param(submitterData);\n\n\n                    \/************************************************************************************** *\/\n                    \/**                                  AJAX                                               *\/\n                    \/** CALL API: (\/wp-json\/saved\/data_in_server) BY AJAX                                   *\/\n                    \/**                                                                                     *\/\n                    \/************************************************************************************** *\/\n                    jQuery.ajax({\n                        url: apiUrl,\n                        method: \"GET\",\n                        data: submitterData\n\n                    }).done(function(response) {\n\n                        \/\/response = JSON.parse(response);\n                        console.log(\"Response:-->\");\n                        console.log(response);\n                        document.getElementById(\"success_submitt\").style.display = 'block';\n                        jQuery('#referralform').trigger(\"reset\"); \n                        jQuery('.api-error').html('').hide();\n\n                    }).fail(function(xhr, status, error) {\n\n                        console.log(xhr, status, error);\n                        var response = xhr.responseText;\n                        var errorMessage = \"Something went wrong. Please try again!\";\n                        jQuery('.api-error').html(errorMessage).show();\n\n                    });\n\/************************************ *\/\n                }\n            });\n\/************************************ *\/\n        });\n    });\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getRequestSelectedOptions()                   *\/\n\/**                         Element: Checkbox                                         *\/\n\/************************************************************************************ *\/\n    function getRequestSelectedOptions() {\n\n        var request_pt = jQuery('#request_pt').val();\n        var request_ot = jQuery('#request_ot').val();\n        var request_wh = jQuery('#request_wh').val();\n        var request_fce = jQuery('#request_fce').val(); \/\/request_aqua\n        var request_aqua = jQuery('#request_aqua').val();\n        var request_vestibular = jQuery('#request_vestibular').val();\n        var request_transport = jQuery('#request_transport').val();\n        var request_mri = jQuery('#request_mri').val();\n        var request_arth = jQuery('#request_arth').val();\n        var request_ct = jQuery('#request_ct').val();\n        var request_xr = jQuery('#request_xr').val();\n        var request_us = jQuery('#request_us').val();\n        var request_emg = jQuery('#request_emg').val();\n        var request_nuc_med = jQuery('#request_nuc_med').val();\n        var request_dme = jQuery('#request_dme').val();\n\n        var selected_options = '';\n\n        \n        if(document.getElementById('request_pt').checked) { selected_options += request_pt + ', '; }\n        if(document.getElementById('request_ot').checked) { selected_options += request_ot + ', '; }\n        if(document.getElementById('request_wh').checked) { selected_options += request_wh + ', '; }\n        if(document.getElementById('request_fce').checked) { selected_options += request_fce + ', '; }\n        if(document.getElementById('request_aqua').checked) { selected_options += request_aqua + ', '; }\n        if(document.getElementById('request_vestibular').checked) { selected_options += request_vestibular + ', '; }\n        if(document.getElementById('request_transport').checked) { selected_options += request_transport + ', '; }\n        if(document.getElementById('request_mri').checked) { selected_options += request_mri + ', '; }\n        if(document.getElementById('request_arth').checked) { selected_options += request_arth + ', '; }\n        if(document.getElementById('request_ct').checked) { selected_options += request_ct + ', '; }\n        if(document.getElementById('request_xr').checked) { selected_options += request_xr + ', '; }\n        if(document.getElementById('request_us').checked) { selected_options += request_us + ', '; }\n        if(document.getElementById('request_emg').checked) { selected_options += request_emg + ', '; }\n        if(document.getElementById('request_nuc_med').checked) { selected_options += request_nuc_med + ', '; }\n        if(document.getElementById('request_dme').checked) { selected_options += request_dme + ', '; }\n\n        let  selected_options_ok =  selected_options.substring(0, selected_options.length - 2);\n        return selected_options_ok;\n    }\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getWorkingYesNo()                             *\/\n\/**                         ELEMENT: Radio Button                                     *\/\n\/************************************************************************************ *\/\n    function getWorkingYesNo(){\n\n        var yes = jQuery('#claimant_working_yes').val();\n        var no = jQuery('#claimant_working_no').val();\n        var working ='';\n        if(document.getElementById('claimant_working_yes').checked) { working = 'yes'; }\n        if(document.getElementById('claimant_working_no').checked) { working = 'no'; }\n\n        return working;\n    }\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getGenderMaleFemale()                         *\/\n\/**                         ELEMENT: Radio Button                                     *\/\n\/************************************************************************************ *\/\n    function getGenderMaleFemale(){\n\n        var female = jQuery('#claimant_gender_female').val();\n        var male = jQuery('#claimant_gender_male').val();\n        var gender = '';\n        if(document.getElementById('claimant_gender_male').checked) { gender = 'Male'; }\n        if(document.getElementById('claimant_gender_female').checked) { gender = 'Female'; }\n\n        return gender;\n    }\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getWorkingHours()                             *\/\n\/**                         ELEMENT: Radio Button                                     *\/\n\/************************************************************************************ *\/\n    function getWorkingHours(){\n        var yes = jQuery('#employee_working_hours_yes').val();\n        var no = jQuery('#employee_working_hours_no').val();\n        var working ='';\n        if(document.getElementById('employee_working_hours_yes').checked) { working = 'yes'; }\n        if(document.getElementById('employee_working_hours_no').checked) { working = 'no'; }\n\n        return working;\n    }\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getRefDoctorPatientHaveSurgery_1()            *\/\n\/**                         ELEMENT: Radio Button                                     *\/\n\/************************************************************************************ *\/\n    function getRefDoctorPatientHaveSurgery_1(){\n\n        var yes = jQuery('#ref_doctor_patient_have_surgery_1_yes').val();\n        var no = jQuery('#ref_doctor_patient_have_surgery_1_no').val();\n        var surgery ='';\n        if(document.getElementById('ref_doctor_patient_have_surgery_1_yes').checked) { surgery = 'yes'; }\n        if(document.getElementById('ref_doctor_patient_have_surgery_1_no').checked) { surgery = 'no'; }\n\n        return surgery;\n   \n    }\n\n\/************************************************************************************ *\/\n\/**                  \t\tFUNCTION :  getRefDoctorScript()                          *\/\n\/**                         ELEMENT: Radio Button                                     *\/\n\/************************************************************************************ *\/\n    function getRefDoctorScript(){\n\n        var yes = jQuery('#ref_doctor_script_yes').val();\n        var no = jQuery('#ref_doctor_script_no').val();\n        var script ='';\n        if(document.getElementById('ref_doctor_script_yes').checked) { script = 'yes'; }\n        if(document.getElementById('ref_doctor_script_no').checked) { script = 'no'; }\n\n        return script;\n    }\n\n\n<\/script>\n<main class=\"container\">\n        <div class=\"alert alert-success\" id=\"success_submitt\">Referral submitted successfully<\/div>\n        <div class=\"alert alert-danger\" id=\"error_submitt\">Please complete Submitter data<\/div>\n         <p class=\"api-error\"><\/p>\n           <!--   <form  id=\"form-upload\" class=\"px-form\" action=\"\" enctype=\"multipart\/form-data\" method=\"post\">\n         <form name=\"referralform\" id=\"referralform\" class=\"px-form\" action=\"\" method=\"post\">\n           <form action=\"\" enctype=\"multipart\/form-data\" method=\"post\" id=\"form-upload\">-->\n           <form name=\"referralform\" id=\"referralform\" class=\"px-form\" action=\"\" method=\"post\">\n                <div class=\"accordion\" id=\"accordionExample\">\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingOne\">\n                            <button class=\"accordion-button\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapseOne\" aria-expanded=\"true\" aria-controls=\"collapseOne\">\n                                Submitter\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapseOne\" class=\"accordion-collapse collapse show\" aria-labelledby=\"headingOne\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body \">\n                                <!-- #########  Submitter ########### -->\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"company_name\" id=\"company_name\"  placeholder=\"Company Name *\" size=\"20\" >\n                                       \n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"first_name\" id=\"first_name\" placeholder=\"First Name *\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"last_name\" id=\"last_name\" placeholder=\"Last Name *\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input required type=\"tel\" class=\"form-control\" name=\"main_phone\" id=\"main_phone\" placeholder=\"Main Phone *\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ext\" id=\"ext\" placeholder=\"Ext.\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"fax\" id=\"fax\" placeholder=\"Fax\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"email\" class=\"form-control\" name=\"email_address\" id=\"email_address\" placeholder=\"email *\">\n                                    <\/div>\n                                <\/div>\n                                <!-- <div class=\"col-auto\">\n                                    <button type=\"submit\" id=\"submitter_button\" class=\"mb-3 custom-btn\">continue<\/button>\n                                <\/div> -->\n        \n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingTwo\">\n                            <button class=\"accordion-button collapsed\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapseTwo\" aria-expanded=\"false\" aria-controls=\"collapseTwo\">\n                                Claimant\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapseTwo\" class=\"accordion-collapse collapse\" aria-labelledby=\"headingTwo\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body\">\n                                <!-- #########  Claimant ########### -->\n                                <div class=\"form-group pb-3\">\n                                    <label>Request:<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_pt\" id=\"request_pt\" value=\"pt\">PT<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_ot\" id=\"request_ot\" value=\"ot\">OT<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_wh\" id=\"request_wh\" value=\"wh\">WH<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_fce\" id=\"request_fce\" value=\"fce\">FCE<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_aqua\" id=\"request_aqua\" value=\"aqua\">AQUA<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_vestibular\" id=\"request_vestibular\" value=\"vestibular\">VESTIBULAR<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_transport\" id=\"request_transport\" value=\"transport\">TRANSPORT<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_mri\" id=\"request_mri\" value=\"mri\">MRI<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_arth\" id=\"request_arth\" value=\"arth\">ARTH<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_ct\" id=\"request_ct\" value=\"ct\">CT<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_xr\" id=\"request_xr\" value=\"xr\">XR<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_us\" id=\"request_us\" value=\"us\">US<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_emg\" id=\"request_emg\" value=\"emg\">EMG<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_nuc_med\" id=\"request_nuc_med\" value=\"nuc.med.\">NUC.MED.<\/label>\n                                    <label class=\"checkbox-inline\"><input type=\"checkbox\" name=\"request_dme\" id=\"request_dme\" value=\"dme\">DME<\/label>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_first_name\" id=\"claimant_first_name\" placeholder=\"First Name\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_last_name\" id=\"claimant_last_name\" placeholder=\"Last Name\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row align-Bottom\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_claimant_number\" id=\"claimant_claimant_number\" placeholder=\"Claimant Number\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <label style=\"display:inline\">Date of Injury <\/label>\n                                        <input required type=\"date\" class=\"form-control\"  name=\"claimant_date_of_injury\" id=\"claimant_date_of_injury\" >\n                                    <\/div>\n                                    \n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_icd_code\" id=\"claimant_icd_code\" placeholder=\"ICD Code\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"pb-3\">\n                                    <input type=\"text\" class=\"form-control\" name=\"claimant_describe\" id=\"claimant_describe\" placeholder=\"Describe Injury\">\n                                <\/div>\n                                <div class=\"form-group\">\n                                    <label>Working?<\/label>\n                                    <label class=\"checkbox-inline\">\n                                        <input name=\"working\" type=\"radio\" name=\"claimant_working_yes\" id=\"claimant_working_yes\" value=\"1\">\n                                        Yes\n                                    <\/label>\n                                    <label class=\"checkbox-inline\">\n                                        <input name=\"working\" type=\"radio\" name=\"claimant_working_no\" id=\"claimant_working_no\" value=\"0\">\n                                        No\n                                    <\/label>\n                                    <input type=\"text\" class=\"form-control with50\"  name=\"claimant_occupation\" id=\"claimant_occupation\" \n                                        placeholder=\"Occupation\">\n                                <\/div>\n                                <div class=\"row mt-3\">\n                                    <div class=\"col-md-4\">\n                                        <div class=\"form-group\">\n                                            <label>Date of Birth<\/label><input required type=\"date\" class=\"form-control\"\n                                                name=\"claimant_date_of_birth\" id=\"claimant_date_of_birth\" >\n                                        <\/div>\n                                    <\/div>\n                                    <div class=\"col-md-5 \">\n                                        <div class=\"form-group \">\n                                            <label>Gender<\/label>\n                                            <div class=\"flex\">\n                                                <label class=\"radio-inline\">\n                                                    <input type=\"radio\" name=\"gender\" id=\"claimant_gender_male\" value=\"1\">Male\n                                                <\/label>\n                                                <label class=\"radio-inline\">\n                                                    <input type=\"radio\" name=\"gender\"  id=\"claimant_gender_female\" value=\"0\">Female\n                                                <\/label>\n                                            <\/div>\n                                        <\/div>\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row mt-3\">\n                                    <div class=\"with25 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_home_phone\" id=\"claimant_home_phone\" placeholder=\"Home Phone\">\n                                    <\/div>\n                                    <div class=\"with25 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_cell_phone\" id=\"claimant_cell_phone\" placeholder=\"Cell Phone\">\n                                    <\/div>\n                                    <div class=\"with25 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_work_phone\" id=\"claimant_work_phone\" placeholder=\"Work Phone\">\n                                    <\/div>\n                                    <div class=\"with25 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_ext\" id=\"claimant_ext\" placeholder=\"Ext.\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with25 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_alternate_phone\" id=\"claimant_alternate_phone\" placeholder=\"Alternate Phone\">\n                                    <\/div>\n                                    <div class=\"with25 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_alt_phone_description\" id=\"claimant_alt_phone_description\" placeholder=\"Alt. Phone Description\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"emial\" class=\"form-control\" name=\"claimant_email_adress\" id=\"claimant_email_adress\" placeholder=\"Email Adress\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_address_1\" id=\"claimant_address_1\" placeholder=\"Address 1\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_address_2\" id=\"claimant_address_2\" placeholder=\"Address 2\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_city\" id=\"claimant_city\" placeholder=\"City\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_state\" id=\"claimant_state\" placeholder=\"State\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"claimant_zip\" id=\"claimant_zip\" placeholder=\"Zip\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"claimant_preferred_language\" id=\"claimant_preferred_language\" placeholder=\"Preferred Language\">\n                                    <\/div>\n        \n                                <\/div>\n                                <!-- <div class=\"col-auto\">\n                                    <button type=\"submit\" id=\"claimant_button\" class=\"mb-3 custom-btn\">continue<\/button>\n                                <\/div> -->\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingThree\">\n                            <button class=\"accordion-button collapsed\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapseThree\" aria-expanded=\"false\" aria-controls=\"collapseThree\">\n                                Employee\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapseThree\" class=\"accordion-collapse collapse\" aria-labelledby=\"headingThree\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body\">\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_company\" id=\"employee_company\" placeholder=\"Company\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_phone_number\" id=\"employee_phone_number\" placeholder=\"Phone number\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_contact\" id=\"employee_contact\" placeholder=\"Contact\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_address1\" id=\"employee_address1\" placeholder=\"Address 1\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_address2\" id=\"employee_address2\" placeholder=\"Address 2\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_city\" id=\"employee_city\" placeholder=\"City\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_state\" id=\"employee_state\" placeholder=\"State\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"employee_zip\" id=\"employee_zip\" placeholder=\"Zip\">\n                                    <\/div>\n                                <\/div>\n        \n                                <div class=\"row\">\n                                    <div class=\"width50\">\n                                        <label>If PT - Schedule during work\n                                            hours?<\/label>\n                                        <label class=\"checkbox-inline\"><input name=\"employee_working_hours\" id=\"employee_working_hours_yes\" type=\"radio\" value=\"1\">\n                                            Yes<\/label>\n                                        <label class=\"checkbox-inline\"><input name=\"employee_working_hours\" id=\"employee_working_hours_no\" type=\"radio\" value=\"0\">\n                                            No<\/label>\n                                    <\/div>\n                                    <div class=\"row pb-3 pt-1\">\n                                        <div class=\"with33 \">\n                                            <label style=\"display:inline\">What hours does patient work?<\/label>\n                                            <input type=\"text\" class=\"form-control\" name=\"date_of_injury\" name=\"employee_date_of_injury\" id=\"employee_date_of_injury\" required>\n                                        <\/div>\n                                    <\/div>\n                                <\/div>\n        \n                                <!-- <div class=\"col-auto\">\n                                    <button type=\"submit\" id=\"employee__button\" class=\"mb-3 custom-btn\">continue<\/button>\n                                <\/div> -->\n                            <\/div>\n                        <\/div>\n                    <\/div>\n        \n                    <!-- ####### Referring Doctor ######## -->\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingfour\">\n                            <button class=\"accordion-button collapsed\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapsefour\" aria-expanded=\"false\" aria-controls=\"collapsefour\">\n                                Referring Doctor\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapsefour\" class=\"accordion-collapse collapse\" aria-labelledby=\"headingfour\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body\">\n        \n        \n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"ref_doctor_first_name\" id=\"ref_doctor_first_name\" placeholder=\"First Name\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input required type=\"text\" class=\"form-control\" name=\"ref_doctor_last_name\" id=\"ref_doctor_last_name\" placeholder=\"Last Name\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_practice_name\" id=\"ref_doctor_practice_name\" placeholder=\"Practice Name\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_phone_number\" id=\"ref_doctor_phone_number\" placeholder=\"Phone Number\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_email_adress\" id=\"ref_doctor_email_adress\" placeholder=\"Email Adress\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_fax\" id=\"ref_doctor_fax\" placeholder=\"Fax\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_adress_1\" id=\"ref_doctor_adress_1\" placeholder=\"Adress 1\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_adress_2\" id=\"ref_doctor_adress_2\" placeholder=\"Adress 2\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_city\" id=\"ref_doctor_city\" placeholder=\"City\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_state\" id=\"ref_doctor_state\" placeholder=\"State\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_zip\" id=\"ref_doctor_zip\" placeholder=\"Zip\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"form-group\">\n                                    <label>Did patient have surgery?<\/label>\n                                    <label class=\"checkbox-inline\">\n                                        <input name=\"patient_have_surgery_1\" type=\"radio\" id=\"ref_doctor_patient_have_surgery_1_yes\" value=\"1\">\n                                        Yes\n                                    <\/label>\n                                    <label class=\"checkbox-inline\">\n                                        <input name=\"patient_have_surgery_1\" type=\"radio\" id=\"ref_doctor_patient_have_surgery_1_no\" value=\"0\">\n                                        No\n                                    <\/label>\n                                    <div class=\"with33 pb-3 pt-2\">\n                                        <label style=\"display:inline\">Surgery Date: <\/label>\n                                        <input type=\"date\" class=\"form-control\"  name=\"ref_doctor_surgery_date\" id=\"ref_doctor_surgery_date\" required=\"\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with50 pb-3 mt-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_dx\" id=\"ref_doctor_dx\" placeholder=\"DX\">\n                                    <\/div>\n                                    <div class=\"with50 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_body_parts\" id=\"ref_doctor_body_parts\" placeholder=\"Body Parts\">\n                                    <\/div>\n                                <\/div>\n                                <div class=\"row\">\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_auth_visits\" id=\"ref_doctor_auth_visits\" placeholder=\"# Auth visits\">\n                                    <\/div>\n                                    <div class=\"with33 pb-3\">\n                                        <input type=\"text\" class=\"form-control\" name=\"ref_doctor_freq_duration\" id=\"ref_doctor_freq_duration\" placeholder=\"Freq\/Duration.\">\n                                    <\/div>\n                                    <div class=\"form-group\">\n                                        <label>Script:<\/label>\n                                        <label class=\"checkbox-inline\">\n                                            <input name=\"script\" type=\"radio\" id=\"ref_doctor_script_yes\" value=\"1\">\n                                            Yes\n                                        <\/label>\n                                        <label class=\"checkbox-inline\">\n                                            <input name=\"script\" type=\"radio\"  id=\"ref_doctor_script_no\" value=\"0\">\n                                            No\n                                        <\/label>\n                                    <\/div>\n                                    <div class=\"with33 pb-3 pt-2\">\n                                        <label style=\"display:inline\">Follow-up MD: <\/label>\n                                        <input type=\"date\" class=\"form-control\"  name=\"ref_doctor_follow_up_md\" id=\"ref_doctor_follow_up_md\" required=\"\">\n                                    <\/div>\n                                <\/div>\n        \n                                <!-- <div class=\"col-auto mt-3\">\n                                    <button id=\"ref_doctor_Button\" type=\"submit\" class=\"mb-3 custom-btn\">continue<\/button>\n                                <\/div> -->\n                            <\/div>\n                        <\/div>\n                    <\/div>\n        \n                    <!-- ######## Attachments ####### -->\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingfive\">\n                            <button class=\"accordion-button collapsed\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapsefive\" aria-expanded=\"false\" aria-controls=\"collapsefive\">\n                                Attachments\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapsefive\" class=\"accordion-collapse collapse\" aria-labelledby=\"headingfive\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body\">                        \n                               <div> <\/div>\n                                    <div>    <section class=\"form-container\">\n        <form action=\"\" enctype=\"multipart\/form-data\" method=\"post\" id=\"form-upload\">\n            <div>\n        <!--    <span>Selecciona alg\u00fan archivo: <\/span>-->\n                <input multiple type=\"file\" id=\"file\" class=\"form-control\" name=\"upload-file\"\/>\n            <\/div>\n        <!-- <input type=\"submit\" id=\"submit\" value=\"Enviar archivo\" \/>-->\n            <div>095ae4268ddb176a<\/div> \n            <input type=\"hidden\" id=\"rand_id_user\" name=\"rand_id_user\" value=\"095ae4268ddb176a\">\n        <\/form>\n\n        <div class=\"alert alert-info\" id=\"message\"><\/div>\n    <\/section>\n                                    <\/div>\n                                <!-- <div class=\"col-auto pt-3\">\n                                    <button type=\"submit\" class=\"mb-3 custom-btn\" id=\"btnSendfile\" >continue<\/button>\n                                    \n                                <\/div> -->\n                                \n                            <\/div>\n                        <\/div>\n                    <\/div>\n        \n                    <!-- ####### Special Instructions ######## -->\n                    <div class=\"accordion-item\">\n                        <h2 class=\"accordion-header\" id=\"headingsix\">\n                            <button class=\"accordion-button collapsed\" type=\"button\" data-bs-toggle=\"collapse\"\n                                data-bs-target=\"#collapsesix\" aria-expanded=\"false\" aria-controls=\"collapsesix\">\n                                Special Instructions\n                            <\/button>\n                        <\/h2>\n                        <div id=\"collapsesix\" class=\"accordion-collapse collapse\" aria-labelledby=\"headingsix\"\n                            data-bs-parent=\"#accordionExample\">\n                            <div class=\"accordion-body\">\n                                <div class=\"form-group\">\n                                    <textarea class=\"form-control\" name=\"special_instructions\" id=\"special_instructions\" placeholder=\"Special Instructions\" rows=\"5\"><\/textarea>\n                                                <\/div>\n                                     <!-- here-->\n                                <div class=\"col-auto pt-3\">\n                                    <button type=\"submit\" name=\"wp-submit\" id=\"wp-submit\"  class=\"mb-3 custom-btn\">Submit<\/button>\n                                <\/div>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n            <\/form> \n        \n           <div><\/div>\n                                  <!--[n_total color=\u2019red\u2019 size=\u201925px\u2019]-->\n                                    <div>                                <\/div>\n            <div class=\"spinner-border text-info\" role=\"status\" id=\"cargando\">\n            <span class=\"visually-hidden\">Loadging...<\/span>\n            <\/div>\n            <\/main>\n\n    \t\t<div class=\"elementor-shortcode\"><\/div>\n\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-a3969a2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"a3969a2\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-13fe5f4\" data-id=\"13fe5f4\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-e6ad4c0 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"e6ad4c0\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 08-05-2024 *\/\n.elementor-widget-divider{--divider-border-style:none;--divider-border-width:1px;--divider-color:#0c0d0e;--divider-icon-size:20px;--divider-element-spacing:10px;--divider-pattern-height:24px;--divider-pattern-size:20px;--divider-pattern-url:none;--divider-pattern-repeat:repeat-x}.elementor-widget-divider .elementor-divider{display:flex}.elementor-widget-divider .elementor-divider__text{font-size:15px;line-height:1;max-width:95%}.elementor-widget-divider .elementor-divider__element{margin:0 var(--divider-element-spacing);flex-shrink:0}.elementor-widget-divider .elementor-icon{font-size:var(--divider-icon-size)}.elementor-widget-divider .elementor-divider-separator{display:flex;margin:0;direction:ltr}.elementor-widget-divider--view-line_icon .elementor-divider-separator,.elementor-widget-divider--view-line_text 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