{"id":296,"date":"2020-07-01T17:05:08","date_gmt":"2020-07-01T17:05:08","guid":{"rendered":"https:\/\/www.heavenlycarephc.com\/todos-los-formularios-de-documentacion\/"},"modified":"2020-07-01T17:05:08","modified_gmt":"2020-07-01T17:05:08","slug":"todos-los-formularios-de-documentacion","status":"publish","type":"page","link":"https:\/\/www.heavenlycarephc.com\/es\/todos-los-formularios-de-documentacion\/","title":{"rendered":"Todos los formularios de documentaci\u00f3n"},"content":{"rendered":"\r\n<p class=\"wp-block-paragraph\">Si no est\u00e1 seguro de si envi\u00f3 toda su evaluaci\u00f3n o si desea enviar una evaluaci\u00f3n previa, puede hacerlo aqu\u00ed.<\/p>\r\n\r\n\r\n\r\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Marzo 21 &#8211; Abril 15<br><\/strong><div data-uniq='6aab0f334eb48' class='uniq-6aab0f334eb48 formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-4 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-4.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-4\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"4\" class=\"fc-form fc-form-4 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left  \" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field14\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field14 options-false index-false form-element-0 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field14\" name=\"field14[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field1 options-false index-false form-element-1 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%; position: relative; z-index: 103; left: 0px; top: 0px\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText is-required-true odd -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >n\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"14\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field3 options-false index-false form-element-3 default-false form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"3\/21 - 4\/15\" class=\"validation-lenient\"><span><span >3\/21 - 4\/15<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field12\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field12 options-false index-false form-element-4 default-false form-element-type-customText is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/p><ul ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<span id=\"selectionBoundary_1593620320987_8612005084784315\" class=\"rangySelectionBoundary\">\ufeff<\/span> F\u00b0 or higher&nbsp;<\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><\/div><input type=\"hidden\" name=\"field12\" data-field-id=\"field12\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field4 options-false index-false form-element-5 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Abril 16 &#8211; Abril 30<br><\/strong><div data-uniq='6aab0f335da00' class='uniq-6aab0f335da00 formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-5 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-5.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-5\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"5\" class=\"fc-form fc-form-5 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left   ng-submitted options-fade\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\" _lpchecked=\"1\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field12\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field12 form-element-0 default-false form-element-type-heading is-required-false odd options-false index-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field12\" name=\"field12[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field1 form-element-1 default-false form-element-type-oneLineText is-required-true options-false index-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText odd is-required-true -handle options-true index-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >N\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"14\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\" autocomplete=\"off\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" form-element form-element-field3 default-false form-element-type-checkbox is-required-true options-false index-false -handle even form-element-3\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"4\/16 - 4\/30\" class=\"validation-lenient\"><span><span >4\/16 - 4\/30<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field16\" data-index=\"4\" style=\"width: 100%; position: relative; z-index: 103; left: 0px; top: -9.75px\" class=\" form-element form-element-field16 default-false form-element-type-customText is-required-false -handle options-false index-false odd form-element-4\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p ><span><span id=\"selectionBoundary_1593620594061_8335118958317929\" class=\"rangySelectionBoundary\">\ufeff<\/span>I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/span><br><\/p><ul style=\"font-size: 13px;text-align: left\" ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><p ><\/p><\/div><input type=\"hidden\" name=\"field16\" data-field-id=\"field16\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" form-element form-element-field4 options-false index-false default-false form-element-type-submit is-required-false -handle even form-element-5\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Mayo 1 &#8211; Mayo 15<br><\/strong><div data-uniq='6aab0f336accf' class='uniq-6aab0f336accf formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-6 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-6.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-6\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"6\" class=\"fc-form fc-form-6 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left  \" style=\"width: 420px; color: #666666; font-size: 100%; background: white\" _lpchecked=\"1\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field12\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field12 options-false index-false form-element-0 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field12\" name=\"field12[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field1 form-element-1 default-false form-element-type-oneLineText is-required-true -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText odd -handle is-required-true options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >N\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"14\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\" autocomplete=\"off\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field3 form-element-3 default-false form-element-type-checkbox is-required-true -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"5\/1 - 5\/15\" class=\"validation-lenient\"><span><span >5\/1 - 5\/15<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field14 form-element-4 default-false form-element-type-customText is-required-false odd -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/p><ul ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><\/div><input type=\"hidden\" name=\"field14\" data-field-id=\"field14\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field4 options-false index-false form-element-5 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-8f761849 wp-block-columns-is-layout-flex\">\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Mayo 16 &#8211; Mayo 30<br><\/strong><div data-uniq='6aab0f3379d43' class='uniq-6aab0f3379d43 formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-7 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-7.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-7\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"7\" class=\"fc-form fc-form-7 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left options-fade  \" style=\"width: 420px; color: #666666; font-size: 100%; background: white\" _lpchecked=\"1\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field12\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field12 form-element-0 default-false form-element-type-heading is-required-false odd -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field12\" name=\"field12[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%; position: relative; z-index: 103; left: 0px; top: 0px\" class=\" even form-element form-element-field1 form-element-1 default-false form-element-type-oneLineText is-required-true -handle options-true index-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%; position: relative; z-index: 103; left: 0px; top: 0px\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText odd -handle is-required-true options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >N\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"14\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\" autocomplete=\"off\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field3 form-element-3 default-false form-element-type-checkbox is-required-true -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"5\/16 - 5\/31\" class=\"validation-lenient\"><span><span >5\/16 - 5\/31<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field14 form-element-4 default-false form-element-type-customText is-required-false odd -handle options-true index-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/p><ul ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><\/div><input type=\"hidden\" name=\"field14\" data-field-id=\"field14\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field4 options-false index-false form-element-5 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Junio 1 &#8211; Junio 15<br><\/strong><div data-uniq='6aab0f3388739' class='uniq-6aab0f3388739 formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-8 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-8.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-8\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"8\" class=\"fc-form fc-form-8 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left   options-fade\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\" _lpchecked=\"1\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field12\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field12 form-element-0 default-false form-element-type-heading is-required-false odd -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field12\" name=\"field12[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field1 form-element-1 default-false form-element-type-oneLineText is-required-true -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText odd -handle is-required-true options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >N\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"14\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\" autocomplete=\"off\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field3 form-element-3 default-false form-element-type-checkbox is-required-true -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"6\/1 - 6\/15\" class=\"validation-lenient\"><span><span >6\/1 - 6\/15<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field14 form-element-4 default-false form-element-type-customText is-required-false odd -handle options-true index-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/p><ul ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<span id=\"selectionBoundary_1593187110389_25468059599186565\" class=\"rangySelectionBoundary\">\ufeff F\u00b0 or higher&nbsp;<\/span><\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><\/div><input type=\"hidden\" name=\"field14\" data-field-id=\"field14\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field4 options-false index-false form-element-5 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n\r\n\r\n\r\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\">\r\n<p class=\"has-text-align-center has-medium-font-size wp-block-paragraph\"><strong>Junio 16 &#8211; Junio 30<br><\/strong><div data-uniq='6aab0f3396a69' class='uniq-6aab0f3396a69 formcraft-css form-live align-left'><div class='form-logic'>[]<\/div><div class=\"fc-pagination-cover fc-pagination-1\">\n\t\t\t\t<div class=\"fc-pagination\" style=\"width: 100%\">\n\t\t\t\t\t<div class=\"pagination-trigger \" data-index=\"0\">\n\t\t\t\t\t\t<span class=\"page-number\"><span >1<\/span><\/span>\n\t\t\t\t\t\t<span class=\"page-name \">Step 1<\/span>\n\t\t\t\t\t\t\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t\n\t\t\t<style scoped=\"scoped\" >\n\t\t\t@media (max-width : 480px) {\n\t\t\t\t.fc_modal-dialog-9 .fc-pagination-cover .fc-pagination\n\t\t\t\t{\n\t\t\t\t\tbackground-color: white !important;\n\t\t\t\t}\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .submit-cover .submit-button,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover .button,\n\t\t\t.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-datepicker .ui-datepicker-title,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .stripe-amount-show\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t.formcraft-datepicker td .ui-state-active,\n\t\t\t.formcraft-datepicker td .ui-state-hover,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbackground: #deb887;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-header,\n\t\t\t.formcraft-css .fc-form .field-cover>div.full hr\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-prev:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker .ui-datepicker-next:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-month:hover,\n\t\t\t#ui-datepicker-div.formcraft-datepicker select.ui-datepicker-year:hover\n\t\t\t{\n\t\t\t\tbackground-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-pagination>div.active .page-number,\n\t\t\t.formcraft-css .form-cover-builder .fc-pagination>div:first-child .page-number\n\t\t\t{\n\t\t\t\tbackground-color: #4488ee;\n\t\t\t\tcolor: #fff;\n\t\t\t}\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar th,\n\t\t\t#ui-datepicker-div.formcraft-datepicker table.ui-datepicker-calendar td.ui-datepicker-today a,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .star-cover label,\n\t\t\thtml .formcraft-css .fc-form.label-floating .form-element .field-cover.has-focus>span,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .customText-cover a,\n\t\t\t.formcraft-css .prev-next>div span:hover\n\t\t\t{\n\t\t\t\tcolor: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .customText-cover a:hover\n\t\t\t{\n\t\t\t\tcolor: #c3a176;\n\t\t\t}\n\t\t\thtml .formcraft-css .fc-form.fc-form-9.label-floating .form-element .field-cover > span\n\t\t\t{\n\t\t\t\tcolor: #666666;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover textarea,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover .time-fields-cover\n\t\t\t{\n\t\t\t\tcolor: #777;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"text\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"password\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"email\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover input[type=\"tel\"],\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover select,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover textarea\n\t\t\t{\n\t\t\t\tbackground-color: #fafafa;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .star-cover label .star\n\t\t\t{\n\t\t\t\ttext-shadow: 0px 1px 0px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .slider-cover .ui-slider-range\n\t\t\t{\n\t\t\t\tbox-shadow: 0px 1px 1px #c3a176 inset;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .fileupload-cover .button-file,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .stripe-amount-show\n\t\t\t{\n\t\t\t\tborder-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .stripe-cover.field-cover div.stripe-amount-show::before\n\t\t\t{\n\t\t\t\tborder-top-color: #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .stripe-cover.field-cover div.stripe-amount-show::after\n\t\t\t{\n\t\t\t\tborder-right-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .stripe-amount-show,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .submit-cover .submit-button .text,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .field-cover .button\n\t\t\t{\n\t\t\t\ttext-shadow: 1px 0px 3px #c3a176;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html input[type=\"password\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html input[type=\"email\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html input[type=\"tel\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html input[type=\"text\"]:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html textarea:focus,\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html select:focus\n\t\t\t{\n\t\t\t\tborder-color: #deb887;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9 .form-element .form-element-html .field-cover .is-read-only:focus {\n\t\t\t\tborder-color: #ccc;\n\t\t\t}\n\t\t\t.formcraft-css .fc-form.fc-form-9\t\t\t{\n\t\t\t\tfont-family: inherit;\n\t\t\t}\n\t\t\t@media (max-width : 480px) {\n\t\t\t\thtml .dedicated-page,\n\t\t\t\thtml .dedicated-page .formcraft-css .fc-pagination > div.active\n\t\t\t\t{\n\t\t\t\t\tbackground: white;\n\t\t\t\t}\n\t\t\t}\n\t\t<\/style>\n\t\t<div class=\"form-cover\">\n\t\t\t<form data-thousand=\"\" data-decimal=\".\" data-delay=\"\" data-id=\"9\" class=\"fc-form fc-form-9 align- fc-temp-class spin- save-form- dont-submit-hidden- remove-asterisk- icons-hide- disable-enter- label-inline frame-visible field-alignment-left options-fade  \" style=\"width: 420px; color: #666666; font-size: 100%; background: white\" _lpchecked=\"1\">\n\t\t\t\t<div class=\"form-page form-page-0\" data-index=\"0\">\n\t\t\t\t\t\n\t\t\t\t\t<div class=\"form-page-content     \">\n\t\t\t\t\t\t<div data-identifier=\"field12\" data-index=\"0\" style=\"width: 100%\" class=\" form-element form-element-field12 options-false index-false form-element-0 default-false form-element-type-heading is-required-false odd -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div style=\"background-color:\" class=\"heading-cover field-cover \"><div style=\"text-align: center; font-size: 1.5em; padding-top: ; padding-bottom: ; color:\" class=\"bold-\"><span >I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios<\/span><\/div><input type=\"hidden\" data-field-id=\"field12\" name=\"field12[]\" value=\"I performed screenings daily \/ Realic\u00e9 ex\u00e1menes de salud diarios\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field1\" data-index=\"1\" style=\"width: 100%\" class=\" even form-element form-element-field1 options-false index-false form-element-1 default-false form-element-type-oneLineText is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Full Name<\/span><\/span><span class=\"sub-label\"><span >Nombre completo<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field1\" name=\"field1[]\" data-min-char=\"\" data-max-char=\"\" data-val-type=\"alphabets\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"true\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-account_circle\">account_circle<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field2\" data-index=\"2\" style=\"width: 100%\" class=\" form-element form-element-field2 form-element-2 default-false form-element-type-oneLineText is-required-true odd -handle options-true index-true\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"oneLineText-cover field-cover \"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Phone Number<\/span><\/span><span class=\"sub-label\"><span >N\u00famero de tel\u00e9fono<\/span><\/span><\/span><div><span class=\"error\"><\/span><input type=\"text\" placeholder=\"\" make-read-only=\"false\" data-field-id=\"field2\" name=\"field2[]\" data-min-char=\"10\" data-max-char=\"14\" data-val-type=\"\" data-regexp=\"\" data-is-required=\"true\" data-allow-spaces=\"\" class=\"validation-lenient\" data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"focus\" data-html=\"true\" data-input-mask=\"(000) 000-0000\" data-mask-placeholder=\"\" data-original-title=\"\"><i class=\"formcraft-icon formcraft-icon-type-phone\">phone<\/i><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field3\" data-index=\"3\" style=\"width: 100%\" class=\" even form-element form-element-field3 options-false index-false form-element-3 default-false form-element-type-checkbox is-required-true -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"images- checkbox-cover field-cover\"><span class=\"sub-label-true\"><span class=\"main-label\"><span >Daily Screenings<\/span><\/span><span class=\"sub-label\"><span >Evaluaci\u00f3n diaria<\/span><\/span><\/span><div data-placement=\"right\" data-toggle=\"tooltip\" tooltip=\"\" data-trigger=\"hover\" data-html=\"true\" data-original-title=\"\"><span class=\"error\"><\/span><label style=\"width:\" ><img alt=\"\"><input data-field-id=\"field3\" type=\"checkbox\" data-is-required=\"true\" name=\"field3[]\" value=\"6\/16 - 6\/30\" class=\"validation-lenient\"><span><span >6\/16 - 6\/30<\/span><\/span><\/label><\/div><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field14\" data-index=\"4\" style=\"width: 100%\" class=\" form-element form-element-field14 form-element-4 default-false form-element-type-customText is-required-false odd -handle options-false index-false\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"absolute-false customText-cover field-cover\" style=\"left: ; top: ;right: ;bottom: ;color: #666666 !important; background-color:\"><div class=\"full\" style=\"text-align: left\"><p >I certify that I am screening myself, the client I care for, and their household members for:&nbsp;<\/p><ul ><li>Travel to foreign locations where covid activity is rampant&nbsp;<\/li><li>New identified covid-related symptoms as updated by the CDC and Texas DSHS&nbsp;<\/li><li>Fever of 100.0<span id=\"selectionBoundary_1593187110389_25468059599186565\" class=\"rangySelectionBoundary\">\ufeff F\u00b0 or higher&nbsp;<\/span><\/li><li>Exposure to individuals either confirmed or suspected cases of Covid-19<\/li><\/ul><\/div><input type=\"hidden\" name=\"field14\" data-field-id=\"field14\"><\/div><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div><div data-identifier=\"field4\" data-index=\"5\" style=\"width: 100%\" class=\" even form-element form-element-field4 options-false index-false form-element-5 default-false form-element-type-submit is-required-false -handle\">\n\t\t\t\t\t\t\t<div class=\"form-element-html\"><div ><div class=\"align-right wide-false submit-cover field-cover\"><button type=\"submit\" class=\"button submit-button\"><span class=\"text \">Submit \/ Entregar<\/span><span class=\"spin-cover\"><i style=\"color:\" class=\"loading-icon icon-cog animate-spin\"><\/i><\/span><\/button><\/div><div class=\"submit-response \"><\/div><input type=\"text\" class=\"required_field \" name=\"website\"><\/div><\/div>\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t<\/form>\n\t\t\t<div class=\"prev-next prev-next-1\" style=\"width: 420px; color: #666666; font-size: 100%; background: white\">\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"inactive page-prev \"><i class=\"formcraft-icon\">keyboard_arrow_left<\/i>Previous<\/span><\/div>\n\t\t\t\t<div><input type=\"text\" class=\"  \"><span class=\"page-next \">Next<i class=\"formcraft-icon\">keyboard_arrow_right<\/i><\/span><\/div>\n\t\t\t<\/div>\n\t\t<\/div><a class=\"powered-by\" target=\"_blank\" href=\"http:\/\/formcraft-wp.com?source=pb\"\/>FormCraft - WordPress form builder<\/a><\/div>\r\n<\/div>\r\n<\/div>\r\n","protected":false},"excerpt":{"rendered":"<p>Si no est\u00e1 seguro de si envi\u00f3 toda su evaluaci\u00f3n o si desea enviar una evaluaci\u00f3n previa, puede hacerlo aqu\u00ed. Marzo 21 &#8211; Abril 15 Abril 16 &#8211; Abril 30 Mayo 1 &#8211; Mayo 15 Mayo 16 &#8211; Mayo 30 Junio 1 &#8211; Junio 15 Junio 16 &#8211; Junio 30<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-296","page","type-page","status-publish","hentry","no-post-thumbnail"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Todos los formularios de documentaci\u00f3n &#8211; Heavenly Care PHC Services<\/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:\/\/www.heavenlycarephc.com\/es\/todos-los-formularios-de-documentacion\/\" \/>\n<meta property=\"og:locale\" content=\"es_ES\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Todos los formularios de documentaci\u00f3n &#8211; Heavenly Care PHC Services\" \/>\n<meta property=\"og:description\" content=\"Si no est\u00e1 seguro de si envi\u00f3 toda su evaluaci\u00f3n o si desea enviar una evaluaci\u00f3n previa, puede hacerlo aqu\u00ed. 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