{"id":945,"date":"2025-09-23T15:34:01","date_gmt":"2025-09-23T15:34:01","guid":{"rendered":"https:\/\/diversiahealth.com\/?page_id=945"},"modified":"2026-01-27T20:51:47","modified_gmt":"2026-01-27T20:51:47","slug":"diabetes-form","status":"publish","type":"page","link":"https:\/\/diversiahealth.com\/es\/diabetes-form\/","title":{"rendered":"Formulario de diabetes"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"945\" class=\"elementor elementor-945\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4747039 e-con-full e-flex magic-button-disabled-no e-con e-parent\" data-id=\"4747039\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-776b95a e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"776b95a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-3c0816a e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"3c0816a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-d79c47a e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"d79c47a\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-652a99c e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"652a99c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-f160d33 e-con-full mesh-bg e-flex magic-button-disabled-no e-con e-child\" data-id=\"f160d33\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-942269b e-con-full elementor-hidden-tablet elementor-hidden-mobile e-flex magic-button-disabled-no e-con e-child\" data-id=\"942269b\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;slideshow&quot;,&quot;background_slideshow_gallery&quot;:[{&quot;id&quot;:1478,&quot;url&quot;:&quot;https:\\\/\\\/diversiahealth.com\\\/wp-content\\\/uploads\\\/2025\\\/12\\\/Untitled-design-34-scaled.png&quot;},{&quot;id&quot;:1479,&quot;url&quot;:&quot;https:\\\/\\\/diversiahealth.com\\\/wp-content\\\/uploads\\\/2025\\\/12\\\/Untitled-design-35-scaled.png&quot;},{&quot;id&quot;:1000,&quot;url&quot;:&quot;https:\\\/\\\/diversiahealth.com\\\/wp-content\\\/uploads\\\/2025\\\/10\\\/WhatsApp-Image-2025-10-09-at-10.52.21-AM.jpeg&quot;},{&quot;id&quot;:985,&quot;url&quot;:&quot;https:\\\/\\\/diversiahealth.com\\\/wp-content\\\/uploads\\\/2025\\\/10\\\/WhatsApp-Image-2025-10-09-at-10.50.16-AM-5.jpeg&quot;},{&quot;id&quot;:1166,&quot;url&quot;:&quot;https:\\\/\\\/diversiahealth.com\\\/wp-content\\\/uploads\\\/2025\\\/11\\\/1-scaled.png&quot;}],&quot;background_slideshow_loop&quot;:&quot;yes&quot;,&quot;background_slideshow_slide_duration&quot;:5000,&quot;background_slideshow_slide_transition&quot;:&quot;fade&quot;,&quot;background_slideshow_transition_duration&quot;:500}\">\n\t\t<div class=\"elementor-element elementor-element-a6002e0 e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"a6002e0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-0200201 e-con-full elementor-hidden-mobile e-flex magic-button-disabled-no e-con e-child\" data-id=\"0200201\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-c6bc0b3 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"c6bc0b3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Join a Clinical Study<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7590a55 elementor-widget__width-initial elementor-widget-mobile__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"7590a55\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t\t\t\t\t\t<p>Complete the form to see if you may qualify for this<em><strong> research study.<\/strong><\/em><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-cf7fa1c e-flex e-con-boxed magic-button-disabled-no e-con e-child\" data-id=\"cf7fa1c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-355a425 e-con-full glass-bg e-flex magic-button-disabled-no e-con e-child\" data-id=\"355a425\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-4ec133f e-con-full e-flex magic-button-disabled-no e-con e-child\" data-id=\"4ec133f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4867a4d elementor-widget elementor-widget-spacer\" data-id=\"4867a4d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3cd5707 elementor-widget elementor-widget-image\" data-id=\"3cd5707\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"800\" height=\"800\" src=\"https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-1024x1024.png\" class=\"attachment-large size-large wp-image-108\" alt=\"\" srcset=\"https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-1024x1024.png 1024w, https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-300x300.png 300w, https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-150x150.png 150w, https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-768x768.png 768w, https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-1536x1536.png 1536w, https:\/\/diversiahealth.com\/wp-content\/uploads\/2025\/07\/diversialogop-2048x2048.png 2048w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-479a426 elementor-widget elementor-widget-heading\" data-id=\"479a426\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">LCTC: Diabetes<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9901cae elementor-widget__width-initial elementor-widget elementor-widget-shortcode\" data-id=\"9901cae\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class='fluentform ff-default fluentform_wrapper_13 ffs_default_wrap'><form data-form_id=\"13\" id=\"fluentform_13\" class=\"frm-fluent-form fluent_form_13 ff-el-form-top ff_form_instance_13_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_13_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Diabetes Type 1 English Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='945' \/><input type=\"hidden\" id=\"_fluentform_13_fluentformnonce\" name=\"_fluentform_13_fluentformnonce\" value=\"241da46944\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/945\" \/><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_names_first_name_' id='label_ff_13_names_first_name_' >First Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_13_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your First Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group ff-el-form-top'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_names_last_name_' id='label_ff_13_names_last_name_' >Last Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_13_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Enter Your Last Name\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_phone' id='label_ff_13_phone' aria-label=\"Phone\/Mobile\">Phone\/Mobile<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" placeholder=\"Mobile Number\" data-name=\"phone\" id=\"ff_13_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_email' id='label_ff_13_email' aria-label=\"Email\">Email<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_13_email\" class=\"ff-el-form-control\" placeholder=\"Email Address\" data-name=\"email\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_13_datetime' id='label_ff_13_datetime' aria-label=\"Date of Birth\">Date of Birth<\/label><\/div><div class='ff-el-input--content'><input  aria-label='Date of Birth Use arrow keys to navigate dates. Press enter to select a date.'  aria-haspopup='dialog' data-type-datepicker data-format='d\/m\/Y' type=\"text\" name=\"datetime\" id=\"ff_13_datetime\" class=\"ff-el-form-control ff-el-datepicker\" placeholder=\"dd\/mm\/yyyy\" data-name=\"datetime\"  aria-invalid='false' aria-required=true><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--label'><label aria-label=\"Address\">Address<\/label><\/div><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_address_1_city_' id='label_ff_13_address_1_city_' aria-label=\"City\">City<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_13_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"City\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_address_1_state_' id='label_ff_13_address_1_state_' aria-label=\"State\">State<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[state]\" id=\"ff_13_address_1_state_\" class=\"ff-el-form-control\" placeholder=\"State\" data-key_name=\"state\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_13_address_1_country_' id='label_ff_13_address_1_country_' aria-label=\"Country\">Country<\/label><\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_13_address_1_country_\" class=\"ff-el-form-control\" placeholder=\"Select Country\" data-key_name=\"country\" aria-invalid='false' aria-required=false><option value=''>Select Country<\/option><option value='AF' >Afghanistan<\/option><option value='AX' >Aland Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Saint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='VG' >British Virgin Islands<\/option><option value='BN' >Brunei<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos (Keeling) Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czech Republic<\/option><option value='CD' >Democratic Republic of the Congo (Kinshasa)<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='CI' >Ivory Coast<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Laos<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., China<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='KP' >North Korea<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestinian Territory<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='CG' >Republic of the Congo (Brazzaville)<\/option><option value='RO' >Romania<\/option><option value='RU' >Russia<\/option><option value='RW' >Rwanda<\/option><option value='RE' >R\u00e9union<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='SX' >Saint Martin (Dutch part)<\/option><option value='MF' >Saint Martin (French part)<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia\/Sandwich Islands<\/option><option value='KR' >South Korea<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom (UK)<\/option><option value='US' >United States (US)<\/option><option value='UM' >United States (US) Minor Outlying Islands<\/option><option value='VI' >United States (US) Virgin Islands<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Do you live with Type 1 Diabetes?\">Do you live with Type 1 Diabetes? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_488b799583dc5be4cc7468d18564f99c'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\" data-calc_value=\"1\"  id='input_radio_488b799583dc5be4cc7468d18564f99c' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7d992b10b256a27e5ed8db4122682a96'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\" data-calc_value=\"0\"  id='input_radio_7d992b10b256a27e5ed8db4122682a96' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Do you currently use insulin?\">Do you currently use insulin? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_5b0500fd26028d75ea14ecb2b2f112d3'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\" data-calc_value=\"1\"  id='input_radio_2_5b0500fd26028d75ea14ecb2b2f112d3' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_58ff4fe1e9f3b6a341e14b3487443e6d'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\" data-calc_value=\"0\"  id='input_radio_2_58ff4fe1e9f3b6a341e14b3487443e6d' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Are you available to visit our office in Tamarac?\">Are you available to visit our office in Tamarac? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_ceef476e43ec6664fd00cd3997da0223'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\" data-calc_value=\"1\"  id='input_radio_3_ceef476e43ec6664fd00cd3997da0223' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_85739fc882fd5d20ad29ddde17194fd0'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\" data-calc_value=\"0\"  id='input_radio_3_85739fc882fd5d20ad29ddde17194fd0' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label   aria-label=\"Preferred language\">Preferred language<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label 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Form\">Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_13_errors' class='ff-errors-in-stack ff_form_instance_13_1 ff-form-loading_errors ff_form_instance_13_1_errors'><\/div><\/div>            <script type=\"text\/javascript\">\n                window.fluent_form_ff_form_instance_13_1 = {\"id\":\"13\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"asteriskPlacement\":\"asterisk-right\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_13_1\",\"form_id_selector\":\"fluentform_13\",\"rules\":{\"names[first_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is 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Complete the form to see if you may qualify for this research study. LCTC: Diabetes<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"apbe_headline":"","apbe_seo_keywords":"","apbe_slug":"","apbe_summary":"","apbe_social":"","footnotes":""},"class_list":["post-945","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/pages\/945","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/comments?post=945"}],"version-history":[{"count":10,"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/pages\/945\/revisions"}],"predecessor-version":[{"id":1778,"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/pages\/945\/revisions\/1778"}],"wp:attachment":[{"href":"https:\/\/diversiahealth.com\/es\/wp-json\/wp\/v2\/media?parent=945"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}