{"id":10047,"date":"2023-11-02T19:44:48","date_gmt":"2023-11-02T19:44:48","guid":{"rendered":"https:\/\/aviva.health\/?page_id=10047"},"modified":"2023-11-02T19:44:48","modified_gmt":"2023-11-02T19:44:48","slug":"patient-family-advisory-council-application","status":"publish","type":"page","link":"https:\/\/aviva.health\/es\/patient-family-advisory-council-application\/","title":{"rendered":"Solicitud para el Consejo Asesor de Familias de Pacientes"},"content":{"rendered":"<style id=\"wpforms-css-vars-10049\">\n\t\t\t\t#wpforms-10049 {\n\t\t\t\t\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-10049\"><form id=\"wpforms-form-10049\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"10049\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/es\/wp-json\/wp\/v2\/pages\/10047\" data-token=\"81f9b525e63af20d1b0dc3a1d5cc42cd\" data-token-time=\"1776057083\"><div class=\"wpforms-head-container\"><div class=\"wpforms-title\">Aviva Health Patient and Family Advisory Council Application<\/div><\/div><noscript class=\"wpforms-error-noscript\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Por favor, activa JavaScript en tu navegador para completar este formulario.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-10049-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Applicant&#039;s Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-10049-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-10049-field_1-error\" required><label for=\"wpforms-10049-field_1\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-10049-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-10049-field_1-last-error\" required><label for=\"wpforms-10049-field_1-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-10049-field_19-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_19\">Applicant&#039;s Date of Birth: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-10049-field_19\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][19][date]\" aria-errormessage=\"wpforms-10049-field_19-error\" required><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-10049-field_20-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_20\">Applicant&#039;s Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-10049-field_20\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][20]\" aria-label=\"Applicant&#039;s Phone\" aria-errormessage=\"wpforms-10049-field_20-error\" required><\/div><div id=\"wpforms-10049-field_12-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_12\">Applicant&#039;s Email: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-10049-field_12\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][12]\" spellcheck=\"false\" aria-errormessage=\"wpforms-10049-field_12-error\" required><\/div><div id=\"wpforms-10049-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_4\">Patient&#039;s Name (if different from above):<\/label><input type=\"text\" id=\"wpforms-10049-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" aria-errormessage=\"wpforms-10049-field_4-error\" ><\/div><div id=\"wpforms-10049-field_18-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_18\">Patient&#039;s Date of Birth:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-10049-field_18\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][18][date]\" aria-errormessage=\"wpforms-10049-field_18-error\" ><a title=\"Clear Date\" data-clear role=\"button\" tabindex=\"0\" class=\"wpforms-datepicker-clear\" aria-label=\"Clear Date\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-10049-field_6-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_6\">Patient&#039;s Provider Name: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-10049-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" aria-errormessage=\"wpforms-10049-field_6-error\" required><\/div><div id=\"wpforms-10049-field_7-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_7\">The Patient is Usually Seen at: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-10049-field_7\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][7]\" required=\"required\"><option value=\"Roseburg Clinic\"  class=\"choice-1 depth-1\"  >Roseburg Clinic<\/option><option value=\"Roseburg Denture Clinic\"  class=\"choice-2 depth-1\"  >Roseburg Denture Clinic<\/option><option value=\"Roseburg Outpatient Behavioral Health Clinic\"  class=\"choice-3 depth-1\"  >Roseburg Outpatient Behavioral Health Clinic<\/option><option value=\"RHS School-based Health Center\"  class=\"choice-4 depth-1\"  >RHS School-based Health Center<\/option><option value=\"North County (Drain) Clinic\"  class=\"choice-5 depth-1\"  >North County (Drain) Clinic<\/option><option value=\"Sutherlin Clinic\"  class=\"choice-6 depth-1\"  >Sutherlin Clinic<\/option><option value=\"Glide Clinic\"  class=\"choice-7 depth-1\"  >Glide Clinic<\/option><option value=\"Myrtle Creek Medical Clinic\"  class=\"choice-8 depth-1\"  >Myrtle Creek Medical Clinic<\/option><option value=\"Myrtle Creek Dental Clinic\"  class=\"choice-9 depth-1\"  >Myrtle Creek Dental Clinic<\/option><\/select><\/div><div id=\"wpforms-10049-field_24-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"24\"><fieldset><legend class=\"wpforms-field-label\">Services Used (check all that apply):<\/legend><ul id=\"wpforms-10049-field_24\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_1\" name=\"wpforms[fields][24][]\" value=\"Family Medicine\" aria-errormessage=\"wpforms-10049-field_24_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_1\">Family Medicine<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_2\" name=\"wpforms[fields][24][]\" value=\"Dental\" aria-errormessage=\"wpforms-10049-field_24_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_2\">Dental<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_3\" name=\"wpforms[fields][24][]\" value=\"Behavioral Health\" aria-errormessage=\"wpforms-10049-field_24_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_3\">Behavioral Health<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_9\" name=\"wpforms[fields][24][]\" value=\"Pediatrics\" aria-errormessage=\"wpforms-10049-field_24_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_9\">Pediatrics<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_8\" name=\"wpforms[fields][24][]\" value=\"Reproductive Health\" aria-errormessage=\"wpforms-10049-field_24_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_8\">Reproductive Health<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_7\" name=\"wpforms[fields][24][]\" value=\"Women&#039;s Health\" aria-errormessage=\"wpforms-10049-field_24_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_7\">Women's Health<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_6\" name=\"wpforms[fields][24][]\" value=\"Lactation Services\" aria-errormessage=\"wpforms-10049-field_24_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_6\">Lactation Services<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_5\" name=\"wpforms[fields][24][]\" value=\"Pharmacy\" aria-errormessage=\"wpforms-10049-field_24_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_5\">Pharmacy<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_4\" name=\"wpforms[fields][24][]\" value=\"Nutrition Services\" aria-errormessage=\"wpforms-10049-field_24_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_4\">Nutrition Services<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_11\" name=\"wpforms[fields][24][]\" value=\"Chronic Care Management\" aria-errormessage=\"wpforms-10049-field_24_11-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_11\">Chronic Care Management<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_24_10\" name=\"wpforms[fields][24][]\" value=\"Vaccinations\" aria-errormessage=\"wpforms-10049-field_24_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_24_10\">Vaccinations<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-10049-field_9-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_9\">What interests you about joining the PFAC? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-10049-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-10049-field_9-error\" required><\/textarea><\/div><div id=\"wpforms-10049-field_10-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_10\">Do you have experience serving on a council or committee? If yes, please describe: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-10049-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-10049-field_10-error\" required><\/textarea><\/div><div id=\"wpforms-10049-field_11-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_11\">What contributions do you feel you could provide to the PFAC? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-10049-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" aria-errormessage=\"wpforms-10049-field_11-error\" required><\/textarea><\/div><div id=\"wpforms-10049-field_14-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_14\">What topics or issues would you like the PFAC to address? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-10049-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-10049-field_14-error\" required><\/textarea><\/div><div id=\"wpforms-10049-field_15-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_15\">What is your availability (ex: first Thursday of every month from noon to 1 p.m.)? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-10049-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-10049-field_15-error\" required><\/textarea><\/div><div id=\"wpforms-10049-field_17-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"17\"><fieldset><legend class=\"wpforms-field-label\">I understand that Umpqua Community Health Center dba Aviva Health (Aviva Health) has a legal and ethical responsibility to maintain patient privacy, including obligations to protect the confidentiality of patient information and to safeguard the privacy of patient information, including but not limited to patient medical records and other individually identifiable health information (collectively referenced herein as &quot;Patient Information&quot;). In addition, I understand that during the course of my visit at Aviva Health, I may see or hear other confidential information such as financial data and\/or operational information pertaining to the organization that Aviva Health is obligated to maintain as confidential (collectively referenced herein as &quot;Confidential Information&quot;). As a condition of my visit or affiliation with Aviva Health, I understand that I must sign and comply with this agreement. By signing this document, I understand and agree that (you must check every box): <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-10049-field_17\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_1\" name=\"wpforms[fields][17][]\" value=\"I will not disclose Patient Information and\/or Confidential Information viewed on my visit without express permission from Aviva Health.\" aria-errormessage=\"wpforms-10049-field_17_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_1\">I will not disclose Patient Information and\/or Confidential Information viewed on my visit without express permission from Aviva Health.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_2\" name=\"wpforms[fields][17][]\" value=\"I will not proceed to any patient or &quot;back of house areas&quot; without being escorted by an authorized Aviva Health employee, unless I have obtained an entry badge and follow all building access procedures.\" aria-errormessage=\"wpforms-10049-field_17_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_2\">I will not proceed to any patient or \"back of house areas\" without being escorted by an authorized Aviva Health employee, unless I have obtained an entry badge and follow all building access procedures.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_3\" name=\"wpforms[fields][17][]\" value=\"I will not access or view any information other than what is required to complete my duties. If I have any question about whether access to certain information is required for me to do my job, I will consult my guide or a Chief Compliance Officer.\" aria-errormessage=\"wpforms-10049-field_17_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_3\">I will not access or view any information other than what is required to complete my duties. If I have any question about whether access to certain information is required for me to do my job, I will consult my guide or a Chief Compliance Officer.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_4\" name=\"wpforms[fields][17][]\" value=\"I will not discuss any information pertaining to the organization in an area where unauthorized individuals may hear such information (for example, in hallways, on elevators, in the break room, on public transportation, at restaurants, and at social events). I understand that is not acceptable to discuss any Patient Information, Confidential Information or other information obtained through my assignment or affiliation with Aviva Health in public areas even if specifics such as a patient&#039;s name a re not used.\" aria-errormessage=\"wpforms-10049-field_17_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_4\">I will not discuss any information pertaining to the organization in an area where unauthorized individuals may hear such information (for example, in hallways, on elevators, in the break room, on public transportation, at restaurants, and at social events). I understand that is not acceptable to discuss any Patient Information, Confidential Information or other information obtained through my assignment or affiliation with Aviva Health in public areas even if specifics such as a patient's name a re not used.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_5\" name=\"wpforms[fields][17][]\" value=\"I will not make inquiries about any information for any individual or party who does not have proper authorization to access such information.\" aria-errormessage=\"wpforms-10049-field_17_5-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_5\">I will not make inquiries about any information for any individual or party who does not have proper authorization to access such information.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_6\" name=\"wpforms[fields][17][]\" value=\"I will not make any unauthorized transmission, copies, disclosures, inquiries, modifications, or purging&#039;s of Patient Information or Confidential Information. Such unauthorized transmissions include, but are not limited to, removing and\/or transferring Patient Information or Confidential Information from Aviva Health&#039;s computer system to unauthorized locations (for instance, home).\" aria-errormessage=\"wpforms-10049-field_17_6-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_6\">I will not make any unauthorized transmission, copies, disclosures, inquiries, modifications, or purging's of Patient Information or Confidential Information. Such unauthorized transmissions include, but are not limited to, removing and\/or transferring Patient Information or Confidential Information from Aviva Health's computer system to unauthorized locations (for instance, home).<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_7\" name=\"wpforms[fields][17][]\" value=\"Upon termination of visit with Aviva Health, I will immediately return all property (e.g. keys, documents, etc.) to Aviva Health.\" aria-errormessage=\"wpforms-10049-field_17_7-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_7\">Upon termination of visit with Aviva Health, I will immediately return all property (e.g. keys, documents, etc.) to Aviva Health.<\/label><\/li><li class=\"choice-11 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_11\" name=\"wpforms[fields][17][]\" value=\"I agree that my obligation under this agreement regarding Patient Information will continue after visit, assignment, or affiliation with Aviva Health.\" aria-errormessage=\"wpforms-10049-field_17_11-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_11\">I agree that my obligation under this agreement regarding Patient Information will continue after visit, assignment, or affiliation with Aviva Health.<\/label><\/li><li class=\"choice-12 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_12\" name=\"wpforms[fields][17][]\" value=\"I understand that violation of this Agreement may result in possible civil or criminal prosecution, or loss of assignment or affiliation with Aviva Health.\" aria-errormessage=\"wpforms-10049-field_17_12-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_12\">I understand that violation of this Agreement may result in possible civil or criminal prosecution, or loss of assignment or affiliation with Aviva Health.<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_10\" name=\"wpforms[fields][17][]\" value=\"I understand that any Confidential Information or Patient Information that I access or view at Aviva Health does not belong to me.\" aria-errormessage=\"wpforms-10049-field_17_10-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_10\">I understand that any Confidential Information or Patient Information that I access or view at Aviva Health does not belong to me.<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_9\" name=\"wpforms[fields][17][]\" value=\"I have read the above Agreement and agree to comply with all its terms as a condition of continuing employment\/assignment\/affiliation.\" aria-errormessage=\"wpforms-10049-field_17_9-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_9\">I have read the above Agreement and agree to comply with all its terms as a condition of continuing employment\/assignment\/affiliation.<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-10049-field_17_8\" name=\"wpforms[fields][17][]\" value=\"I have received a signed copy of this document.\" aria-errormessage=\"wpforms-10049-field_17_8-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-10049-field_17_8\">I have received a signed copy of this document.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-10049-field_22-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"22\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-10049-field_22\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][22][first]\" aria-errormessage=\"wpforms-10049-field_22-error\" required><label for=\"wpforms-10049-field_22\" class=\"wpforms-field-sublabel after\">Nombre<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-10049-field_22-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][22][last]\" aria-errormessage=\"wpforms-10049-field_22-last-error\" required><label for=\"wpforms-10049-field_22-last\" class=\"wpforms-field-sublabel after\">Apellidos<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-10049-field_21-container\" class=\"wpforms-field wpforms-field-signature\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-10049-field_21\">Signature: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-10049-field_21\" class=\"wpforms-signature-input wpforms-screen-reader-element wpforms-field-required\" data-is-wrapped-field=\"1\" name=\"wpforms[fields][21]\" autocomplete=\"off\" inputmode=\"none\" aria-errormessage=\"wpforms-10049-field_21-error\" required><div class=\"wpforms-signature-wrap wpforms-field-row wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-10049-field_21-signature\" data-color=\"#000000\"><\/canvas><div class=\"wpforms-signature-clear\" title=\"Clear Signature\" tabindex=\"0\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"1em\" height=\"1em\" preserveAspectRatio=\"xMidYMid meet\" viewBox=\"0 0 1536 1536\">\n\t\t\t\t\t<path fill=\"var( --wpforms-field-text-color, rgba(0, 0, 0, 0.25) )\" d=\"M1149 994q0-26-19-45L949 768l181-181q19-19 19-45q0-27-19-46l-90-90q-19-19-46-19q-26 0-45 19L768 587L587 406q-19-19-45-19q-27 0-46 19l-90 90q-19 19-19 46q0 26 19 45l181 181l-181 181q-19 19-19 45q0 27 19 46l90 90q19 19 46 19q26 0 45-19l181-181l181 181q19 19 45 19q27 0 46-19l90-90q19-19 19-46zm387-226q0 209-103 385.5T1153.5 1433T768 1536t-385.5-103T103 1153.5T0 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style=\"display:none;\"><\/a><\/div><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"10049\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/aviva.health\/es\/wp-json\/wp\/v2\/pages\/10047\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-10049\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/aviva.health\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Cargando\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"Aviva Health Patient and Family Advisory Council ApplicationPor favor, activa JavaScript en tu navegador para completar este formulario.Por favor, activa JavaScript en tu navegador para completar este formulario.Applicant&#039;s Name: *NombreApellidosApplicant&#039;s 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