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fbIsTestResponse = 'False',
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fbRenderContainer = document.createElement("div"),
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fbConfigScript = document.createElement("script"),
fbRequireJSScript = document.createElement("script"),
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fbGeoCaptchaCallback = document.createElement("script"),
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renderedScripts = 'var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
\
fbRequire([\'jquery\', \'he\'], function ($, he) {\
he.encode.options.decimal = true;\
he.encode.options.allowUnsafeSymbols = true;\
\
var sectionConditions = JSON.parse(\'[{"ElementName":"FormField139_d4e13973-ca0d-4b56-8097-411392b867d9","Value":"Otra"}]\');\
var conditionOperator = \'and\';\
\
sectionConditions.forEach(function (sectionCondition) {\
$("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
\
$("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
checkShowHide();\
});\
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$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
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$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
checkShowHide();\
});\
});\
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function checkShowHide() {\
var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
sectionConditions.forEach(function (sectionCondition) {\
checkSelect(sectionCondition); \
checkCheckbox(sectionCondition); \
checkRadio(sectionCondition); \
});\
\
showHideSection(shouldShowSection);\
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function checkSelect(sectionCondition) {\
var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
if (!matchingSelect) {\
return;\
}\
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if (matchingSelect.type === \'select-multiple\') {\
var hasOneMatchingValue = false;\
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for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
hasOneMatchingValue = true;\
}\
}\
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shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
} else {\
shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
}\
}\
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function checkCheckbox(sectionCondition) {\
var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
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for (var i = 0; i < matchingCheckboxes.length; i++) {\
if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
}\
}\
}\
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function checkRadio(sectionCondition) {\
var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
\
for (var i = 0; i < matchingRadios.length; i++) {\
if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
}\
}\
}\
}\
\
function mergeCondition(overallResult, newResult, element) {\
newResult = newResult && isParentVisible(element);\
\
if (conditionOperator === \'and\') {\
return overallResult && newResult;\
} else {\
return overallResult || newResult;\
}\
}\
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function isParentVisible(element) {\
var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
return parentSectionDiv && !parentSectionDiv.is(":hidden");\
}\
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function encode(myString) {\
myString = he.encode(he.escape(myString));\
\
/* Fixes issues with single quote and backtick encoding */\
var i,\
entities = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
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for (i = 0; i < entities.length; i++) {\
myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
}\
\
return myString;\
}\
\
function showHideSection(showSection) {\
if (showSection) {\
$(\'#FormField140_d4e13973-ca0d-4b56-8097-411392b867d9\').show();\
} else {\
$(\'#FormField140_d4e13973-ca0d-4b56-8097-411392b867d9\').hide();\
}\
\
$("#FormField140_d4e13973-ca0d-4b56-8097-411392b867d9 .conditionalSectionListSelection").each(function (i, obj) {\
if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
if (obj.checked) {\
$(\'#\' + obj.id).change();\
}\
} else {\
$(\'#\' + obj.id).change();\
}\
});\
}\
});\
});\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
\
fbRequire([\'jquery\', \'he\'], function ($, he) {\
he.encode.options.decimal = true;\
he.encode.options.allowUnsafeSymbols = true;\
\
var sectionConditions = JSON.parse(\'[{"ElementName":"FormField17_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Si"}]\');\
var conditionOperator = \'and\';\
\
sectionConditions.forEach(function (sectionCondition) {\
$("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
\
$("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
checkShowHide();\
});\
});\
\
function checkShowHide() {\
var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
sectionConditions.forEach(function (sectionCondition) {\
checkSelect(sectionCondition); \
checkCheckbox(sectionCondition); \
checkRadio(sectionCondition); \
});\
\
showHideSection(shouldShowSection);\
\
function checkSelect(sectionCondition) {\
var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
if (!matchingSelect) {\
return;\
}\
\
if (matchingSelect.type === \'select-multiple\') {\
var hasOneMatchingValue = false;\
\
for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
hasOneMatchingValue = true;\
}\
}\
\
shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
} else {\
shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
}\
}\
\
function checkCheckbox(sectionCondition) {\
var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
\
for (var i = 0; i < matchingCheckboxes.length; i++) {\
if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
}\
}\
}\
\
function checkRadio(sectionCondition) {\
var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
\
for (var i = 0; i < matchingRadios.length; i++) {\
if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
}\
}\
}\
}\
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function mergeCondition(overallResult, newResult, element) {\
newResult = newResult && isParentVisible(element);\
\
if (conditionOperator === \'and\') {\
return overallResult && newResult;\
} else {\
return overallResult || newResult;\
}\
}\
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function isParentVisible(element) {\
var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
return parentSectionDiv && !parentSectionDiv.is(":hidden");\
}\
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function encode(myString) {\
myString = he.encode(he.escape(myString));\
\
/* Fixes issues with single quote and backtick encoding */\
var i,\
entities = [\
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[\'`\', \'`\']\
];\
\
for (i = 0; i < entities.length; i++) {\
myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
}\
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return myString;\
}\
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function showHideSection(showSection) {\
if (showSection) {\
$(\'#FormField131_d4e13973-ca0d-4b56-8097-411392b867d9\').show();\
} else {\
$(\'#FormField131_d4e13973-ca0d-4b56-8097-411392b867d9\').hide();\
}\
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$("#FormField131_d4e13973-ca0d-4b56-8097-411392b867d9 .conditionalSectionListSelection").each(function (i, obj) {\
if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
if (obj.checked) {\
$(\'#\' + obj.id).change();\
}\
} else {\
$(\'#\' + obj.id).change();\
}\
});\
}\
});\
});\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
\
fbRequire([\'jquery\', \'he\'], function ($, he) {\
he.encode.options.decimal = true;\
he.encode.options.allowUnsafeSymbols = true;\
\
var sectionConditions = JSON.parse(\'[{"ElementName":"FormField32_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Si"}]\');\
var conditionOperator = \'and\';\
\
sectionConditions.forEach(function (sectionCondition) {\
$("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
\
$("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
checkShowHide();\
});\
});\
\
function checkShowHide() {\
var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
sectionConditions.forEach(function (sectionCondition) {\
checkSelect(sectionCondition); \
checkCheckbox(sectionCondition); \
checkRadio(sectionCondition); \
});\
\
showHideSection(shouldShowSection);\
\
function checkSelect(sectionCondition) {\
var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
if (!matchingSelect) {\
return;\
}\
\
if (matchingSelect.type === \'select-multiple\') {\
var hasOneMatchingValue = false;\
\
for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
hasOneMatchingValue = true;\
}\
}\
\
shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
} else {\
shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
}\
}\
\
function checkCheckbox(sectionCondition) {\
var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
\
for (var i = 0; i < matchingCheckboxes.length; i++) {\
if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
}\
}\
}\
\
function checkRadio(sectionCondition) {\
var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
\
for (var i = 0; i < matchingRadios.length; i++) {\
if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
}\
}\
}\
}\
\
function mergeCondition(overallResult, newResult, element) {\
newResult = newResult && isParentVisible(element);\
\
if (conditionOperator === \'and\') {\
return overallResult && newResult;\
} else {\
return overallResult || newResult;\
}\
}\
\
function isParentVisible(element) {\
var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
return parentSectionDiv && !parentSectionDiv.is(":hidden");\
}\
\
function encode(myString) {\
myString = he.encode(he.escape(myString));\
\
/* Fixes issues with single quote and backtick encoding */\
var i,\
entities = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
for (i = 0; i < entities.length; i++) {\
myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
}\
\
return myString;\
}\
\
function showHideSection(showSection) {\
if (showSection) {\
$(\'#FormField129_d4e13973-ca0d-4b56-8097-411392b867d9\').show();\
} else {\
$(\'#FormField129_d4e13973-ca0d-4b56-8097-411392b867d9\').hide();\
}\
\
$("#FormField129_d4e13973-ca0d-4b56-8097-411392b867d9 .conditionalSectionListSelection").each(function (i, obj) {\
if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
if (obj.checked) {\
$(\'#\' + obj.id).change();\
}\
} else {\
$(\'#\' + obj.id).change();\
}\
});\
}\
});\
});\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
\
fbRequire([\'jquery\', \'he\'], function ($, he) {\
he.encode.options.decimal = true;\
he.encode.options.allowUnsafeSymbols = true;\
\
var sectionConditions = JSON.parse(\'[{"ElementName":"FormField50_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Si"}]\');\
var conditionOperator = \'and\';\
\
sectionConditions.forEach(function (sectionCondition) {\
$("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
\
$("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
checkShowHide();\
});\
});\
\
function checkShowHide() {\
var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
sectionConditions.forEach(function (sectionCondition) {\
checkSelect(sectionCondition); \
checkCheckbox(sectionCondition); \
checkRadio(sectionCondition); \
});\
\
showHideSection(shouldShowSection);\
\
function checkSelect(sectionCondition) {\
var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
if (!matchingSelect) {\
return;\
}\
\
if (matchingSelect.type === \'select-multiple\') {\
var hasOneMatchingValue = false;\
\
for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
hasOneMatchingValue = true;\
}\
}\
\
shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
} else {\
shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
}\
}\
\
function checkCheckbox(sectionCondition) {\
var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
\
for (var i = 0; i < matchingCheckboxes.length; i++) {\
if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
}\
}\
}\
\
function checkRadio(sectionCondition) {\
var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
\
for (var i = 0; i < matchingRadios.length; i++) {\
if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
}\
}\
}\
}\
\
function mergeCondition(overallResult, newResult, element) {\
newResult = newResult && isParentVisible(element);\
\
if (conditionOperator === \'and\') {\
return overallResult && newResult;\
} else {\
return overallResult || newResult;\
}\
}\
\
function isParentVisible(element) {\
var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
return parentSectionDiv && !parentSectionDiv.is(":hidden");\
}\
\
function encode(myString) {\
myString = he.encode(he.escape(myString));\
\
/* Fixes issues with single quote and backtick encoding */\
var i,\
entities = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
for (i = 0; i < entities.length; i++) {\
myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
}\
\
return myString;\
}\
\
function showHideSection(showSection) {\
if (showSection) {\
$(\'#FormField127_d4e13973-ca0d-4b56-8097-411392b867d9\').show();\
} else {\
$(\'#FormField127_d4e13973-ca0d-4b56-8097-411392b867d9\').hide();\
}\
\
$("#FormField127_d4e13973-ca0d-4b56-8097-411392b867d9 .conditionalSectionListSelection").each(function (i, obj) {\
if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
if (obj.checked) {\
$(\'#\' + obj.id).change();\
}\
} else {\
$(\'#\' + obj.id).change();\
}\
});\
}\
});\
});\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
\
fbRequire([\'jquery\', \'he\'], function ($, he) {\
he.encode.options.decimal = true;\
he.encode.options.allowUnsafeSymbols = true;\
\
var sectionConditions = JSON.parse(\'[{"ElementName":"FormField54_b9060325-6262-487a-b018-81c9fe1c35b8","Value":"Si"}]\');\
var conditionOperator = \'and\';\
\
sectionConditions.forEach(function (sectionCondition) {\
$("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\
\
$("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\
checkShowHide();\
});\
\
$("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\
checkShowHide();\
});\
});\
\
function checkShowHide() {\
var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\
\
sectionConditions.forEach(function (sectionCondition) {\
checkSelect(sectionCondition); \
checkCheckbox(sectionCondition); \
checkRadio(sectionCondition); \
});\
\
showHideSection(shouldShowSection);\
\
function checkSelect(sectionCondition) {\
var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\
\
if (!matchingSelect) {\
return;\
}\
\
if (matchingSelect.type === \'select-multiple\') {\
var hasOneMatchingValue = false;\
\
for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\
if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\
hasOneMatchingValue = true;\
}\
}\
\
shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\
} else {\
shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\
}\
}\
\
function checkCheckbox(sectionCondition) {\
var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\
\
for (var i = 0; i < matchingCheckboxes.length; i++) {\
if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\
}\
}\
}\
\
function checkRadio(sectionCondition) {\
var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\
\
for (var i = 0; i < matchingRadios.length; i++) {\
if (encode(matchingRadios[i].value) === sectionCondition.Value) {\
shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\
}\
}\
}\
}\
\
function mergeCondition(overallResult, newResult, element) {\
newResult = newResult && isParentVisible(element);\
\
if (conditionOperator === \'and\') {\
return overallResult && newResult;\
} else {\
return overallResult || newResult;\
}\
}\
\
function isParentVisible(element) {\
var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\
return parentSectionDiv && !parentSectionDiv.is(":hidden");\
}\
\
function encode(myString) {\
myString = he.encode(he.escape(myString));\
\
/* Fixes issues with single quote and backtick encoding */\
var i,\
entities = [\
[\''\', \''\'],\
[\'`\', \'`\']\
];\
\
for (i = 0; i < entities.length; i++) {\
myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\
}\
\
return myString;\
}\
\
function showHideSection(showSection) {\
if (showSection) {\
$(\'#FormField134_d4e13973-ca0d-4b56-8097-411392b867d9\').show();\
} else {\
$(\'#FormField134_d4e13973-ca0d-4b56-8097-411392b867d9\').hide();\
}\
\
$("#FormField134_d4e13973-ca0d-4b56-8097-411392b867d9 .conditionalSectionListSelection").each(function (i, obj) {\
if (obj.type === \'radio\' || obj.type === \'checkbox\') {\
if (obj.checked) {\
$(\'#\' + obj.id).change();\
}\
} else {\
$(\'#\' + obj.id).change();\
}\
});\
}\
});\
});\
};\
\
fbRequireJSScript.addEventListener("load", conditionalSectionJs);var conditionalSectionJs = function () {\
requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\
var fbRequire = fbRequireConfig.fbRequire;\
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Required fields are marked with *
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Llenar todos los requisitos marcados con astrisco*
Complete TODAS las secciones de este formulario para que podamos brindarle una atención adecuada a su hijo/a. Debe completar una aplicación por cada niño. Esta información se mantendrá confidencial.
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Su niño/a a experimentado alguno de los siguientes problemas medicos?
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CONSENTIMIENTO PARA RECIBIR TRATAMIENTO
DOY MI CONSENTIMIENTO para que el personal odontológico del Hospital de niños de St. Chistopher’s le proporcione los siguientes servicios dentales, incluyendo radiografías, limpieza, selladores, floruro , inyección de algún agente anestésico (anestesia local), terapia neural, tratamiento de conducto, coronas, extracciones de dientes y/o empastes dentales que necesite mi hijo/a luego de un examen realizado por un dentista licenciado mediante el programa de atención móvil del cuidado dental de Ronald McDonald. Si mi hijo/a necesita servicios adicionales, debo aceptar la prestación de los servicios antes de que se proporcionen.
Comprendo que los riesgos asociados a los tratamientos dentales son poco frecuentes, no obstante pueden ocurrir. Dichos riesgos son una posible reacción alérgica o irritación de los tejidos a la anestesia local, dolor, molestia e inflamación. Entiendo que es mi responsabilidad notificar al personal odontológico (dental) acerca de cualquier cambio en la salud o los medicamentos de mi hijo/a. Comprendo que si tengo dudas o inquietudes, debo llamar a la coordinadora del programa dental al 215-427-8877, antes de firmar este consentimiento.
Si el/la niño/a asiste a la escuela, doy mi permiso para que mi hijo/a sea llevado fuera del aula y acompañado hasta el sitio en que se presta la atención del cuidado dental movil de Ronald McDonald, que se estacionará frente a la escuela de mi hijo/a. Ciertos tratamientos pueden proporcionarse dentro del edificio escolar. Es posible que desee, o no, estar presente al momento de la visita del dentista. Entiendo que puedo solicitar un plan de tratamiento dental para mi hijo/a en cualquier momento.
Reconozco que he recibido el Aviso de prácticas de privacidad del Hospital de niños de St. Christopher’s y conservaré una copia para mis registros.
Autorizo al Hospital de niños de St. Christopher’s a que le proporcione a la escuela de mi hijo/a una copia del informe del examen dental y de los servicios prestados. Comprendo que el que St. Christopher le entregará una copia del informe a la escuela para que ésta pueda mantener registros completos sobre la salud de mi hijo/a. Este consentimiento es válido por un año desde la fecha firmada.
Doy permiso para que se le facturen a mi seguro todos los cargos que correspondan y comprendo que no se me facturará ningún saldo por los cargos que no cubra Medicaid. Para los servicios dentales proporcionados a los beneficiarios de Medicaid, el pago y el cumplimiento del reclamo presentado por el proveedor de los servicios se realizarán con fondos federales y estatales y, del mismo modo, cualquier afirmación falsa, declaración de documento u ocultamiento de hechos materiales estarán sujetos al procesamiento de conformidad con las leyes federales y estatales vigentes.
El que suscribe tiene derecho a revocar el presente consentimiento en cualquier momento, ya sea mediante una solicitud verbal o escrita.
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Todos los pacientes reciben unaNotificación sobre Practicas de Privacidad (NPP.)En esta Notificación sobre Prácticas de Privacidad se identifica: (1) Ia forma en que se puede usar o revelar información médica sobre usted; (2) el derecho que tiene de acceder a su información médica, de enmendar su información médica, de solicitar una relación de las revelaciones de su información médica y de solicitar restricciones adicionales sobre los usos y revelaciones de dicha información; (3) el derecho que tiene de presentar quejas si considera que se han violado sus derechos sobre privacidad; y (4) la responsabilidad que tenemos nosotros de mantener la privacidad de su información médica.