{"id":54412,"date":"2024-07-11T16:55:44","date_gmt":"2024-07-11T14:55:44","guid":{"rendered":"https:\/\/biorius.com\/informe-de-acontecimientos-adversos\/informe-de-acontecimientos-adversos-la-experiencia-ayurveda\/"},"modified":"2025-10-02T11:27:36","modified_gmt":"2025-10-02T09:27:36","slug":"informe-de-acontecimientos-adversos-la-experiencia-ayurveda","status":"publish","type":"page","link":"https:\/\/biorius.com\/es\/informe-de-acontecimientos-adversos-la-experiencia-ayurveda\/","title":{"rendered":"Informe de acontecimientos adversos La experiencia Ayurveda"},"content":{"rendered":"\n<div data-elementor-type=\"wp-page\" data-elementor-id=\"54412\" class=\"elementor elementor-54412 elementor-51515\" data-elementor-post-type=\"page\">\n<div class=\"elementor-element elementor-element-826f706 e-flex e-con-boxed e-con e-parent\" data-id=\"826f706\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-77839fe elementor-widget elementor-widget-heading\" data-id=\"77839fe\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n<div class=\"elementor-widget-container\">\n<h1 class=\"elementor-heading-title elementor-size-default\">Adverse Event Report<\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-de650c5 elementor-widget elementor-widget-html\" data-id=\"de650c5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n<div class=\"elementor-widget-container\">\n<div class=\"breadcrumbs\">\n<ul>\n<li>\n            <a href=\"https:\/\/biorius.com\/\">Home<\/a>\n        <\/li>\n<li>\n            <a href=\"#\">Adverse Event Report<\/a>\n        <\/li>\n<\/ul>\n<\/div><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-db22b43 e-flex e-con-boxed e-con e-parent\" data-id=\"db22b43\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-844cc51 elementor-widget elementor-widget-image\" data-id=\"844cc51\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"225\" height=\"225\" src=\"https:\/\/biorius.com\/wp-content\/uploads\/2024\/06\/Theayurvedaexperience.webp\" class=\"attachment-large size-large wp-image-51481\" alt=\"\" srcset=\"https:\/\/biorius.com\/wp-content\/uploads\/2024\/06\/Theayurvedaexperience.webp 225w, https:\/\/biorius.com\/wp-content\/uploads\/2024\/06\/Theayurvedaexperience-150x150.jpg 150w\" sizes=\"(max-width: 225px) 100vw, 225px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-55c4d61 e-con-full e-flex e-con e-child\" data-id=\"55c4d61\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-3925cbd elementor-widget elementor-widget-heading\" data-id=\"3925cbd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n<div class=\"elementor-widget-container\">\n<h1 class=\"elementor-heading-title elementor-size-default\">Cosmetic Product Safety<br \/>Reporting Health Issue:<\/h1>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-19aacf6 e-flex e-con-boxed e-con e-parent\" data-id=\"19aacf6\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-fb2e514 e-con-full e-flex e-con e-child\" data-id=\"fb2e514\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"elementor-element elementor-element-2b49c59 elementor-widget elementor-widget-text-editor\" data-id=\"2b49c59\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n<div class=\"elementor-widget-container\">\n<p><span style=\"color: #93d500;\"><strong>Your Well-being is Our Priority<\/strong><\/span><br \/>We understand your misfortune and we are sincerely sorry for you. We will investigate the case, but we need your help: please just fill in the form for the bad or unwanted reactions you encountered and submit it and you will be contacted by one of our experts. Thank you very much for your contribution and we hope you will get well soon.<\/p>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<\/p><\/div>\n<div class=\"elementor-element elementor-element-2990177 e-flex e-con-boxed e-con e-parent\" data-id=\"2990177\" data-element_type=\"container\" data-e-type=\"container\">\n<div class=\"e-con-inner\">\n<div class=\"elementor-element elementor-element-0ccd793 elementor-widget__width-inherit elementor-widget elementor-widget-gk_elementor_gravity_form\" data-id=\"0ccd793\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"gk_elementor_gravity_form.default\">\n<div class=\"elementor-widget-container\">\n<div class=\"gk-gravity-form\"><script>\nvar 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obligatorios<\/p>\n<\/p><\/div>\n<form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/es\/wp-json\/wp\/v2\/pages\/54412' data-formid='4' novalidate>\n<div class='gf_invisible ginput_recaptchav3' data-sitekey='6LeU9SIqAAAAAFxZQ73mH3MP9-aJLNPkaprZhj7H' data-tabindex='0'><input id=\"input_1c9cb9763a57953039690a5d3630d98b\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_1c9cb9763a57953039690a5d3630d98b\" value=\"\"\/><\/div>\n<div class='gform-body gform_body'>\n<div id='gform_fields_4' class='gform_fields top_label form_sublabel_above description_below validation_below'>\n<div id=\"field_4_71\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--honeypot gfield--\"  data-field-class=\"gfield--honeypot gfield--\" ><label class='gfield_label gform-field-label' for='input_4_71'>Email<\/label><\/p>\n<div class='ginput_container'><input name='input_71' id='input_4_71' type='text' value='' autocomplete='new-password'\/><\/div>\n<div class='gfield_description' id='gfield_description_4_71'>Este campo es un campo de validaci\u00f3n y debe quedar sin cambios.<\/div>\n<\/div>\n<fieldset id=\"field_4_69\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--consent gfield--large\"  data-field-class=\"gfield--consent gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_container ginput_container_consent'><input name='input_69.1' id='input_4_69_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_69_1' >I agree to the processing of my personal data.<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input type='hidden' name='input_69.2' value='I agree to the processing of my personal data.' class='gform_hidden' \/><input type='hidden' name='input_69.3' value='2' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_70\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_above gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--consent gfield--large\"  data-field-class=\"gfield--consent gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<\/legend>\n<div class='ginput_container ginput_container_consent'><input name='input_70.1' id='input_4_70_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_4_70_1' >I agree that this data may be shared with the distributor and\/or the cosmetic product brand and\/or authorities of my country.<\/label><input type='hidden' name='input_70.2' value='I agree that this data may be shared with the distributor and\/or the cosmetic product brand and\/or authorities of my country.' class='gform_hidden' \/><input type='hidden' name='input_70.3' value='2' class='gform_hidden' \/><\/div>\n<\/fieldset>\n<div id=\"field_4_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--medium\"  data-field-class=\"gfield--section gfield--medium\" >\n<h3 class=\"gsection_title\">A. Consumer Information<\/h3>\n<\/div>\n<fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_1'>\n<p>                            <span id='input_4_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value=''   aria-required='false'    autocomplete=\"given-name\" \/><br \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nombre<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_66\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_66'>\n<p>                            <span id='input_4_66_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_66.6' id='input_4_66_6' value=''   aria-required='false'    autocomplete=\"family-name\" \/><br \/>\n                                                    <label for='input_4_66_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Apellidos<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<div id=\"field_4_61\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_61'>Date of Birth<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_4_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_61_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_61_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_61' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<fieldset id=\"field_4_27\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Sex<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_27'>\n<div class='gchoice gchoice_4_27_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.1' type='checkbox'  value='Male'  id='choice_4_27_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_1' id='label_4_27_1' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.2' type='checkbox'  value='Female'  id='choice_4_27_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_2' id='label_4_27_2' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.3' type='checkbox'  value='Undifferentiated'  id='choice_4_27_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_3' id='label_4_27_3' class='gform-field-label gform-field-label--type-inline'>Undifferentiated<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_27_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_27.4' type='checkbox'  value='Decline to answer'  id='choice_4_27_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_27_4' id='label_4_27_4' class='gform-field-label gform-field-label--type-inline'>Decline to answer<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_4_26\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Ethnicity<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_26'>\n<div class='gchoice gchoice_4_26_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.1' type='checkbox'  value='American Indian\/Alaska Native'  id='choice_4_26_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_1' id='label_4_26_1' class='gform-field-label gform-field-label--type-inline'>American Indian\/Alaska Native<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.2' type='checkbox'  value='Black or African American'  id='choice_4_26_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_2' id='label_4_26_2' class='gform-field-label gform-field-label--type-inline'>Black or African American<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.3' type='checkbox'  value='Asian'  id='choice_4_26_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_3' id='label_4_26_3' class='gform-field-label gform-field-label--type-inline'>Asian<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.4' type='checkbox'  value='Native Hawaiian\/Other Pacific Islander'  id='choice_4_26_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_4' id='label_4_26_4' class='gform-field-label gform-field-label--type-inline'>Native Hawaiian\/Other Pacific Islander<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.5' type='checkbox'  value='Hispanic\/Latino'  id='choice_4_26_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_5' id='label_4_26_5' class='gform-field-label gform-field-label--type-inline'>Hispanic\/Latino<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_26_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_26.6' type='checkbox'  value='Caucasian'  id='choice_4_26_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_26_6' id='label_4_26_6' class='gform-field-label gform-field-label--type-inline'>Caucasian<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"field_4_28\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Gender: Enter the patient\u2019s current gender (how the patient thinks of themself).<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_28'>\n<div class='gchoice gchoice_4_28_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.1' type='checkbox'  value='Cisgender man\/boy (gender corresponds with birth sex)'  id='choice_4_28_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_1' id='label_4_28_1' class='gform-field-label gform-field-label--type-inline'>Cisgender man\/boy (gender corresponds with birth sex)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.2' type='checkbox'  value='Cisgender woman\/girl (gender corresponds with birth sex)'  id='choice_4_28_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_2' id='label_4_28_2' class='gform-field-label gform-field-label--type-inline'>Cisgender woman\/girl (gender corresponds with birth sex)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.3' type='checkbox'  value='Transgender man\/trans man\/ (female-to-male)'  id='choice_4_28_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_3' id='label_4_28_3' class='gform-field-label gform-field-label--type-inline'>Transgender man\/trans man\/ (female-to-male)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.4' type='checkbox'  value='Transgender woman\/trans woman\/ (male-to-female)'  id='choice_4_28_4'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_4' id='label_4_28_4' class='gform-field-label gform-field-label--type-inline'>Transgender woman\/trans woman\/ (male-to-female)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.5' type='checkbox'  value='Other gender category'  id='choice_4_28_5'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_5' id='label_4_28_5' class='gform-field-label gform-field-label--type-inline'>Other gender category<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_28_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_28.6' type='checkbox'  value='Decline to answer'  id='choice_4_28_6'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_28_6' id='label_4_28_6' class='gform-field-label gform-field-label--type-inline'>Decline to answer<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_4_29\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">B. Adverse Event or Product Problem<\/h3>\n<\/div>\n<fieldset id=\"field_4_30\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--checkbox gfield--large\"  data-field-class=\"gfield--checkbox gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of Report (check all that apply)<\/legend>\n<div class='ginput_container ginput_container_checkbox'>\n<div class='gfield_checkbox ' id='input_4_30'>\n<div class='gchoice gchoice_4_30_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.1' type='checkbox'  value='Product problem (e.g. defects\/malfunctions)'  id='choice_4_30_1'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_1' id='label_4_30_1' class='gform-field-label gform-field-label--type-inline'>Product problem (e.g. defects\/malfunctions)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_30_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.2' type='checkbox'  value='Adverse event (e.g. allergy, irritation, \u2026)'  id='choice_4_30_2'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_2' id='label_4_30_2' class='gform-field-label gform-field-label--type-inline'>Adverse event (e.g. allergy, irritation, \u2026)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<div class='gchoice gchoice_4_30_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_30.3' type='checkbox'  value='Serious adverse event (e.g. permanent damage, hospitalization, life-threatening, \u2026)'  id='choice_4_30_3'   \/><br \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_30_3' id='label_4_30_3' class='gform-field-label gform-field-label--type-inline'>Serious adverse event (e.g. permanent damage, hospitalization, life-threatening, \u2026)<\/label>\n\t\t\t\t\t\t\t<\/div>\n<\/div>\n<\/div>\n<\/fieldset>\n<div id=\"field_4_64\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_64'>Date of Event<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_64' id='input_4_64' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_64_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_64_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_64' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_62\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_62'>Date of this Report<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_62' id='input_4_62' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='06\/10\/2026' aria-describedby=\"input_4_62_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_62_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_62' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--textarea gfield--large\"  data-field-class=\"gfield--textarea gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_34'>Describe Event or Problem<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_4_34' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_4_35\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--textarea gfield--large\"  data-field-class=\"gfield--textarea gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_35'>Additional comments and other relevant history (e.g. allergies, pregnancy, tobacco product use, alcohol use, etc.)<\/label><\/p>\n<div class='ginput_container ginput_container_textarea'><textarea name='input_35' id='input_4_35' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div>\n<\/div>\n<div id=\"field_4_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">C. Suspect Product<\/h3>\n<\/div>\n<div id=\"field_4_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_65'>Brand name<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_65' id='input_4_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_44'>Product Name<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_44' id='input_4_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_49'>Lot #<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_49' id='input_4_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_51'>Dose or Amount<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_51' id='input_4_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--text gfield--large\"  data-field-class=\"gfield--text gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_52'>Frequency<\/label><\/p>\n<div class='ginput_container ginput_container_text'><input name='input_52' id='input_4_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--date gfield--large\"  data-field-class=\"gfield--date gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_63'>Expiration Date<\/label><\/p>\n<div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_4_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_4_63_date_format\" aria-invalid=\"false\" \/><br \/>\n                            <span id='input_4_63_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n<p>                        <input type='hidden' id='gforms_calendar_icon_input_4_63' class='gform_hidden' value='https:\/\/biorius.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div>\n<div id=\"field_4_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection information-title field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--section gfield--large\"  data-field-class=\"gfield--section gfield--large\" >\n<h3 class=\"gsection_title\">D. Initial Reporter<\/h3>\n<\/div>\n<fieldset id=\"field_4_55\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_hidden gfield--name gfield--large\"  data-field-class=\"gfield--name gfield--large\" >\n<div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div>\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_4_55'>\n<p>                            <span id='input_4_55_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <label for='input_4_55_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label><br \/>\n                                                    <input type='text' name='input_55.3' id='input_4_55_3' value=''   aria-required='true'     \/><br \/>\n                                                <\/span><\/p>\n<p>                            <span id='input_4_55_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                            <label for='input_4_55_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label><br \/>\n                                                            <input type='text' name='input_55.6' id='input_4_55_6' value=''   aria-required='true'     \/><br \/>\n                                                        <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_67\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_67'>\n<p>                            <span id='input_4_67_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_67.3' id='input_4_67_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/><br \/>\n                                                    <label for='input_4_67_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Nombre<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_68\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--name gfield--medium\"  data-field-class=\"gfield--name gfield--medium\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>\n<div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_4_68'>\n<p>                            <span id='input_4_68_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' ><br \/>\n                                                    <input type='text' name='input_68.6' id='input_4_68_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/><br \/>\n                                                    <label for='input_4_68_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Apellidos<\/label><br \/>\n                                                <\/span><\/p><\/div>\n<\/fieldset>\n<fieldset id=\"field_4_54\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--address gfield--large\"  data-field-class=\"gfield--address gfield--large\" >\n<legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/legend>\n<div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_4_54' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_54_1_container' ><br \/>\n                                        <label for='input_4_54_1' id='input_4_54_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label><br \/>\n                                        <input type='text' name='input_54.1' id='input_4_54_1' value=''    aria-required='false'    \/><br \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_4_54_2_container' ><br \/>\n                                        <label for='input_4_54_2' id='input_4_54_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label><br \/>\n                                        <input type='text' name='input_54.2' id='input_4_54_2' value=''     aria-required='false'   \/><br \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_54_3_container' ><br \/>\n                                    <label for='input_4_54_3' id='input_4_54_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label><br \/>\n                                    <input type='text' name='input_54.3' id='input_4_54_3' value=''    aria-required='false'    \/><br \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_4_54_4_container' ><br \/>\n                                        <label for='input_4_54_4' id='input_4_54_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label><br \/>\n                                        <input type='text' name='input_54.4' id='input_4_54_4' value=''      aria-required='false'    \/><br \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_4_54_5_container' ><br \/>\n                                    <label for='input_4_54_5' id='input_4_54_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label><br \/>\n                                    <input type='text' name='input_54.5' id='input_4_54_5' value=''    aria-required='false'    \/><br \/>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_4_54_6_container' ><br \/>\n                                        <label for='input_4_54_6' id='input_4_54_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label><br \/>\n                                        <select name='input_54.6' id='input_4_54_6'   aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select><br \/>\n                                    <\/span><\/p>\n<div class='gf_clear gf_clear_complex'><\/div>\n<\/p><\/div>\n<\/fieldset>\n<div id=\"field_4_56\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--phone gfield--large\"  data-field-class=\"gfield--phone gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_56'>Phone<\/label><\/p>\n<div class='ginput_container ginput_container_phone'><input name='input_56' id='input_4_56' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div>\n<\/div>\n<div id=\"field_4_57\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--email gfield--large\"  data-field-class=\"gfield--email gfield--large\" ><label class='gfield_label gform-field-label' for='input_4_57'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><\/p>\n<div class='ginput_container ginput_container_email'>\n                            <input name='input_57' id='input_4_57' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button gform-button--width-full' 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