{"id":13197,"date":"2020-12-27T19:57:22","date_gmt":"2020-12-27T19:57:22","guid":{"rendered":"https:\/\/www.fisiosurid.com\/researchcovid19\/?page_id=13197"},"modified":"2020-12-27T20:27:25","modified_gmt":"2020-12-27T20:27:25","slug":"sign-up","status":"publish","type":"page","link":"https:\/\/www.fisiosurid.com\/researchcovid19\/sign-up\/","title":{"rendered":"Sign Up"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 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class=\"fusion-title title fusion-title-1 fusion-title-center fusion-title-text fusion-title-size-two\" style=\"margin-top:0px;margin-right:0px;margin-bottom:30px;margin-left:0px;\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep-\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h2 class=\"title-heading-center\" style=\"margin:0;\"><h3 style=\"text-align: center;\">SIGN UP FOR PATIENTS<\/h3>\n<hr \/>\n<h3 style=\"text-align: center;\"><\/h3><\/h2><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><div class=\"fusion-section-separator section-separator waves fusion-section-separator-2\"><div class=\"fusion-section-separator-svg\" style=\"font-size:0;line-height:0;\"><svg class=\"fusion-waves-candy\" fill=\"#010589\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" version=\"1.1\" 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method=\"post\" class=\"fusion-form fusion-form-13202\"><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"background-color: rgba(255,255,255,0);background-position: center center;background-repeat: no-repeat;border-width: 0px 0px 0px 0px;border-color:#eae9e9;border-style:solid;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start\" style=\"width:104% !important;max-width:104% !important;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"first_name\">Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"first_name\" id=\"first_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"First name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-1{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-1 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-1{width:100% !important;order : 0;}.fusion-builder-column-1 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"last_name\">Last Name <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"last_name\" id=\"last_name\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Last name*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-2{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-2 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-2{width:100% !important;order : 0;}.fusion-builder-column-2 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body 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id=\"phone\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Phone number*\" data-holds-private-data=\"false\" pattern=\"[0-9()#&+*-=.]+\" title=\"Only numbers and phone characters are accepted.\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-3{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-3 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-3{width:100% !important;order : 0;}.fusion-builder-column-3 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-email-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"email\">Email<\/label><\/div><div class=\"fusion-form-input-with-icon\"><i class=\"fa-envelope fas\"><\/i><input type=\"email\" name=\"email\" id=\"email\" value=\"\"  class=\"fusion-form-input\" placeholder=\"Your email\" data-holds-private-data=\"false\"\/><\/div><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-4{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-4 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-4{width:100% !important;order : 0;}.fusion-builder-column-4 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"address_1\">Address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-5{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-5 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-5{width:100% !important;order : 0;}.fusion-builder-column-5 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"address_1\">Address <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"address_1\" id=\"address_1\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Address line 1*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-6{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-6 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-6{width:100% !important;order : 0;}.fusion-builder-column-6 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"city\">City <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"city\" id=\"city\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"City*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-7{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-7 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-7{width:100% !important;order : 0;}.fusion-builder-column-7 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"country\">Country <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"country\" id=\"country\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Country*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-8{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-8 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-8{width:100% !important;order : 0;}.fusion-builder-column-8 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"asymptomatic?\">Are you asymptomatic? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"asymptomatic?\" id=\"asymptomatic?\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Are you asymptomatic?*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-9{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-9 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-9{width:100% !important;order : 0;}.fusion-builder-column-9 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"BeforeCovid\">Before COVID-19, indicate the chronic disease that you suffered (if you did not have, write NONE)  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"BeforeCovid\" id=\"BeforeCovid\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Before COVID-19, indicate the chronic disease that you suffered (if you did not have, write NONE) *\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-10{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-10 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-10{width:100% !important;order : 0;}.fusion-builder-column-10 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-11 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"hospitalized\">Have you ever been hospitalized for COVID19?  <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"hospitalized\" id=\"hospitalized\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Have you ever been hospitalized for COVID19? *\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-11{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-11 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-11{width:100% !important;order : 0;}.fusion-builder-column-11 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-12 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"currently\">Do you currently have COVID19 symptoms? <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"currently\" id=\"currently\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Do you currently have COVID19 symptoms?*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-12{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-12 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-12{width:100% !important;order : 0;}.fusion-builder-column-12 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-13 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"13202\"><label for=\"date_of_last_positive_covid-19_test\">Date of last positive COVID-19 test<\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"date_of_last_positive_covid-19_test\" name=\"date_of_last_positive_covid-19_test\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Date of last positive COVID-19 test\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-13{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-13 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-13{width:100% !important;order : 0;}.fusion-builder-column-13 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-14 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-date-field fusion-form-label-above\" data-form-id=\"13202\"><label for=\"Applicationdate\">Application date<\/label><input autocomplete=\"no\" type=\"date\" data-format=\"\" tabindex=\"\" id=\"Applicationdate\" name=\"Applicationdate\" data-type=\"custom\" value=\"\" data-holds-private-data=\"false\" class=\"fusion-form-input\" placeholder=\"Application date\"autocomplete=\"no\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-14{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-14 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-14{width:100% !important;order : 0;}.fusion-builder-column-14 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-15 fusion_builder_column_1_2 1_2 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;padding: 0px 0px 0px 0px;\"><div class=\"fusion-form-field fusion-form-text-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><label for=\"doubts\">Doubts or Study Questions that I need to clarify (if you have no doubts, write NONE) <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/label><\/div><input type=\"text\" name=\"doubts\" id=\"doubts\" value=\"\"  class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" placeholder=\"Doubts or Study Questions that I need to clarify (if you have no doubts, write NONE)*\" data-holds-private-data=\"false\" minlength=\"0\"\/><\/div><\/div><style type=\"text\/css\">.fusion-body .fusion-builder-column-15{width:50% !important;margin-top : 0px;margin-bottom : 0px;}.fusion-builder-column-15 > .fusion-column-wrapper {padding-top : 0px !important;padding-right : 0px !important;margin-right : 3.84%;padding-bottom : 0px !important;padding-left : 0px !important;margin-left : 3.84%;}@media only screen and (max-width:1024px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}@media only screen and (max-width:640px) {.fusion-body .fusion-builder-column-15{width:100% !important;order : 0;}.fusion-builder-column-15 > .fusion-column-wrapper {margin-right : 1.92%;margin-left : 1.92%;}}<\/style><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-16 fusion_builder_column_1_1 1_1 fusion-flex-column\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\" style=\"background-position:left top;background-repeat:no-repeat;-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover;background-color:#f3fafc;border-width: 1px 1px 1px 1px;border-color:#b8e0ee;border-style:solid;padding: 35px 45px 35px 45px;\"><style type=\"text\/css\">@media only screen and (max-width:1024px) {.fusion-title.fusion-title-2{margin-top:0px!important; margin-right:0px!important;margin-bottom:30px!important;margin-left:0px!important;}}@media only screen and (max-width:640px) {.fusion-title.fusion-title-2{margin-top:0px!important; margin-right:0px!important;margin-bottom:20px!important; margin-left:0px!important;}}<\/style><div class=\"fusion-title title fusion-title-2 fusion-title-text fusion-title-size-two\" style=\"margin-top:0px;margin-right:0px;margin-bottom:30px;margin-left:0px;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep-\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h2 class=\"title-heading-left\" style=\"margin:0;\">Rules of participation<\/h2><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep-\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-1\"><p><b>1.<\/b><span lang=\"en\"> To participate, you must view the informative video contained on this website, you must carefully read the documents hosted on this website called Patient Information Sheet, and Patient Informed Consent. In addition, you must meet the inclusion criteria, and you must complete and submit this registration form, filling in all the required fields. Remember that your participation is free, voluntary, and you can leave the study when you consider it appropriate, without giving us any explanation for it.<\/span><\/p>\n<\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-bottom:20px;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#e0dede;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-text fusion-text-2\"><p><strong>2.\u00a0INCLUSION CRITERIA<\/strong><\/p>\n<ul>\n<li class=\"p1\">You must be between 18-75 years old<\/li>\n<li class=\"p1\">You must have symptoms consistent with COVID-19 after having close contact with a COVID-19 infected patient, or you have tested positive for coronavirus (COVID-19) polymerase chain reaction (PCR), or in the antigen test, from 40 days before the start of the study, or up to 10 days after it.<\/li>\n<\/ul>\n<\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-bottom:20px;width:100%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"border-color:#e0dede;border-top-width:1px;\"><\/div><\/div><div class=\"fusion-text fusion-text-3\"><p><strong>3. INFORMED CONSENT<\/strong><\/p>\n<ul>\n<li class=\"p1\">I have been able to ask questions about the study, speaking with one of the researchers, or through email (cleofas@us.es).<\/li>\n<li class=\"p1\">I have been able to receive enough information about the study.<\/li>\n<li class=\"p1\">I understand that my authorization is voluntary.<\/li>\n<li class=\"p1\">I understand that I can withdraw from the study: \/\/ 1. When you want, of your own free will. \/\/ 2. Without having to explain my decision. \/\/ 3. Without this affecting my health care.<\/li>\n<li class=\"p1\">I freely grant my consent to participate in the study.<\/li>\n<li class=\"p1\">I give my consent to participate in this study.<\/li>\n<\/ul>\n<\/div><div class=\"fusion-form-field fusion-form-checkbox-field fusion-form-label-above\" data-form-id=\"13202\"><div class=\"fusion-form-label-wrapper\"><span class=\"label\">AUTHORIZATION OF INFORMED CONSENT <abbr class=\"fusion-form-element-required\" title=\"required\">*<\/abbr><\/span><\/div><fieldset><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-agree-1-0\" type=\"checkbox\" value=\"I have read the documents hosted on this website, called \"PATIENT INFORMATION SHEET\" and \"INFORMED CONSENT FOR STUDY PATIENTS\"\" name=\"agree[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-agree-1-0\">I have read the documents hosted on this website, called \"PATIENT INFORMATION SHEET\" and \"INFORMED CONSENT FOR STUDY PATIENTS\"<\/label><\/div><div class=\"fusion-form-checkbox\"><input tabindex=\"\" id=\"checkbox-agree-1-1\" type=\"checkbox\" value=\"I AUTHORIZE my participation in the study, and I GIVE my informed consent\" name=\"agree[]\" class=\"fusion-form-input\" required=\"true\" aria-required=\"true\" data-holds-private-data=\"false\"\/><label for=\"checkbox-agree-1-1\">I AUTHORIZE my participation in the study, and I GIVE my informed consent<\/label><\/div><\/fieldset><\/div><div class=\"form-submission-notices\" id=\"fusion-notices-1\"><div class=\"fusion-alert alert success alert-success fusion-alert-center fusion-form-response fusion-form-response-success fusion-alert-capitalize alert-dismissable\" style=\"background-color:#dff0d8;color:rgba(92,163,64,1);border-color:rgba(92,163,64,1);border-width:1px;margin-top:30px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-check-circle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">Thank you for your message. It has been sent.<\/span><\/div><\/div><div class=\"fusion-alert alert error alert-danger fusion-alert-center fusion-form-response fusion-form-response-error fusion-alert-capitalize alert-dismissable\" style=\"background-color:#f2dede;color:rgba(166,66,66,1);border-color:rgba(166,66,66,1);border-width:1px;margin-top:30px;\"><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><div class=\"fusion-alert-content-wrapper\"><span class=\"alert-icon\"><i class=\"fa-lg fa fa-exclamation-triangle\" aria-hidden=\"true\"><\/i><\/span><span class=\"fusion-alert-content\">There was an error trying to send your message. 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