{"id":5124,"date":"2024-06-21T11:36:21","date_gmt":"2024-06-21T16:36:21","guid":{"rendered":"https:\/\/cedarhealthresearch.com\/?page_id=5124"},"modified":"2025-11-12T06:43:13","modified_gmt":"2025-11-12T11:43:13","slug":"derivacion-medica","status":"publish","type":"page","link":"https:\/\/cedarhealthresearch.com\/es\/physician-referral\/","title":{"rendered":"Formulario de remisi\u00f3n m\u00e9dica"},"content":{"rendered":"<div class=\"wpb-content-wrapper\" id=\"wpb-content-root\"><div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12 vc_col-lg-offset-2 vc_col-lg-8 vc_col-md-offset-1 vc_col-md-10 vc_col-sm-offset-0\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<p>Complete el formulario a continuaci\u00f3n para referir a un paciente a cualquiera de nuestros estudios de investigaci\u00f3n.<\/p>\n<p class=\"wp-block-paragraph\">\n\n\t\t<\/div>\n\t<\/div>\n<\/div><\/div><\/div><\/div><div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12 vc_col-lg-offset-2 vc_col-lg-8 vc_col-md-offset-1 vc_col-md-10\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5136-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"5136\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/es\/wp-json\/wp\/v2\/pages\/5124#wpcf7-f5136-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Formulario de contacto\" novalidate=\"novalidate\" data-status=\"init\" data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/5124#wpcf7-f5136-o1\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"5136\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5136-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<p><label> <strong>Nombre del estudio \/ Condici\u00f3n<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Study-Name-Condition\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u00bfA qu\u00e9 ensayo se refiere?\" value=\"\" type=\"text\" name=\"Study-Name-Condition\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>Nombre completo del paciente<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patient-Full-Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre y apellido requeridos\" value=\"\" type=\"text\" name=\"Patient-Full-Name\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>Fecha de nacimiento del paciente<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Patient-Date-of-Birth\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"DD\/MM\/AAAA\" value=\"\" type=\"date\" name=\"Patient-Date-of-Birth\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>Direcci\u00f3n de correo electr\u00f3nico del paciente<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PatientEmailAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"El paciente recibir\u00e1 confirmaci\u00f3n en este correo electr\u00f3nico.\" value=\"\" type=\"email\" name=\"PatientEmailAddress\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>N\u00famero de tel\u00e9fono del paciente<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"PatientPhoneNumber\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"(XXX) XXX-XXXX\" value=\"\" type=\"tel\" name=\"PatientPhoneNumber\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>Nombre del m\u00e9dico<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Physician-Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Physician-Name\" \/><\/span><\/label>\n<\/p>\n<p><label> <strong>Nombre de la pr\u00e1ctica<\/strong> <span style=\"color: red\";>*<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Practice-Name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Practice-Name\" \/><\/span><\/label>\n<\/p>\n<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Consent\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"Consent\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">&nbsp;<strong>Doy mi consentimiento para que se realicen actividades de divulgaci\u00f3n relacionadas con el ensayo en nombre de mi paciente.<\/strong><\/span><\/label><\/span><\/span><\/span> &nbsp;<span style=\"color: red\";>*<\/span>\n<\/p>\n<p><span style=\"margin-bottom:25px;\">\n\t<\/span>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Entregar\" \/>\n<\/p><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>\u0394<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"9\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Rellene el siguiente formulario para remitir a un paciente a cualquiera de nuestros estudios de investigaci\u00f3n. Nombre del estudio \/ afecci\u00f3n * Nombre completo del paciente * Fecha de nacimiento del paciente * Direcci\u00f3n de correo electr\u00f3nico del paciente * N\u00famero de tel\u00e9fono del paciente * Nombre del m\u00e9dico * Nombre de la consulta * Doy mi consentimiento para la divulgaci\u00f3n relacionada con el ensayo en nombre de mi paciente * \u0394<\/p>","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"class_list":["post-5124","page","type-page","status-publish","hentry","description-off"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 5.0.2 - aioseo.com -->\n\t<meta name=\"description\" content=\"Complete the form below to refer a patient to any of our research studies. 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