<!-- Note :
   - You can modify the font style and form style to suit your website.
   - Code lines with comments Do not remove this code are required for the form to work properly, make sure that you do not remove these lines of code.
   - The Mandatory check script can modified as to suit your business needs.
   - It is important that you test the modified form before going live.-->
<div id='crmWebToEntityForm' class='zcwf_lblLeft crmWebToEntityForm' style='background-color:#ffffff;color:#000000;max-width:720px;border-radius:18px;box-shadow:0 15px 40px rgba(0,0,0,0.18);'>
	<meta name='viewport' content='width=device-width, initial-scale=1.0'>
	<meta http-equiv='content-type' content='text/html;charset=UTF-8'>

	<form id='webform7139392000001107011' action='https://crm.zoho.com/crm/WebToLeadForm' name='WebToLeads7139392000001107011' method='POST' onsubmit='javascript:document.charset="UTF-8"; return checkMandatory7139392000001107011()' accept-charset='UTF-8'>

		<input type='text' style='display:none;' name='xnQsjsdp' value='ab665059452237dc4fd37d871077e2fc23dca5eb26fa65205a0c8d84de04cbe5'>
		<input type='hidden' name='zc_gad' id='zc_gad' value=''>
		<input type='text' style='display:none;' name='xmIwtLD' value='157193fb2c78bb36db7655282e6585c04b49cd59d28d1b9530435d6018982236711bdce7fd643b8bf01c62f84fbafb73'>
		<input type='text' style='display:none;' name='actionType' value='TGVhZHM='>
		<input type='text' style='display:none;' name='returnURL' value='https://wa.me/56926058681'>

		<!-- Do not remove this code. -->
		<style>
			html, body {
				margin: 0;
				padding: 0;
				font-family: Arial, sans-serif;
			}

			#crmWebToEntityForm.zcwf_lblLeft {
				width: 100%;
				padding: 32px;
				margin: 0 auto;
				box-sizing: border-box;
				background: #ffffff4f;
				border-radius: 30px;
				box-shadow: 0 15px 40px rgba(0,0,0,0.18);
			}


			#crmWebToEntityForm.zcwf_lblLeft * {
				box-sizing: border-box;
			}

			#crmWebToEntityForm {
				text-align: left;
			}

			#crmWebToEntityForm * {
				direction: ltr;
			}

			.zcwf_lblLeft .zcwf_title {
				display: none !important;
			}
.zpform-container h2 {
    display: none !important;;
}
.zpform-container input[type='text'], .zpform-container input[type='email'], .zpform-container input[type='date'], .zpform-container input[type="file"], .zpform-container textarea, .zpform-container select, input, textarea, select {
    background: #ffffff4f!important;
    border-color: #ffffff;
    border-radius: 10px;
    }
.zpform-container .zpbutton.zpbutton-type-primary {
    background-color: #3B81F0!important;
    color: #FFFFFF;
    border-color: transparent;
}

			.zcwf_lblLeft .zcwf_row {
				margin: 18px 0;
			}

			.zcwf_lblLeft .zcwf_row:after,
			.zcwf_lblLeft .zcwf_col_fld:after,
			.cBoth:after {
				content: '';
				display: table;
				clear: both;
			}

			.zcwf_lblLeft .zcwf_col_lab {
				width: 30%;
				word-break: break-word;
				padding: 10px 14px 0 0;
				margin: 0;
				float: left;
				min-height: 1px;
				font-size: 15px !important;
				font-weight: 600;
				color: #1f2937;
				line-height: 1.4;
			}

			.zcwf_lblLeft .zcwf_col_fld {
				float: left;
				width: 70%;
				padding: 0;
				position: relative;
				margin-top: 0;
			}

			/*.zcwf_lblLeft .zcwf_col_fld input[type=text],
			.zcwf_lblLeft .zcwf_col_fld input[type=password],
			.zcwf_lblLeft .zcwf_col_fld textarea,
			.zcwf_lblLeft .zcwf_col_fld_slt {
				width: 100%;
				border: 1px solid #c8d0db !important;
				background: #f7f9fc;
				border-radius: 10px;
				float: left;
				padding: 12px 14px;
				font-size: 15px;
				min-height: 48px;
				outline: none;
				resize: vertical;
			}

			.zcwf_lblLeft .zcwf_col_fld input[type=text]:focus,
			.zcwf_lblLeft .zcwf_col_fld textarea:focus,
			.zcwf_lblLeft .zcwf_col_fld_slt:focus {
				border: 1px solid #6578FF !important;
				box-shadow: 0 0 0 3px rgba(101,120,255,0.12);
				background: #ffffff;
			}*/

			.zcwf_lblLeft .zcwf_col_help {
				display: none;
			}

			.zcwf_lblLeft .zcwf_privacy {
				padding: 6px;
			}

			.zcwf_lblLeft .wfrm_fld_dpNn {
				display: none;
			}

			.dIB {
				display: inline-block;
			}

			.zcwf_lblLeft .zcwf_help_icon {
				cursor: pointer;
				width: 16px;
				height: 16px;
				display: inline-block;
				background: #fff;
				border: 1px solid #c0c6cc;
				color: #c1c1c1;
				text-align: center;
				font-size: 11px;
				line-height: 16px;
				font-weight: bold;
				border-radius: 50%;
			}

			.zcwf_lblLeft .formsubmit {
				margin-right: 0;
				cursor: pointer;
				font-size: 16px;
				font-weight: 700;
			}

			.formsubmit.zcwf_button {
				color: white !important;
				background: linear-gradient(90deg, #6578FF, #4DBAB6) !important;
				border: none !important;
				border-radius: 999px !important;
				padding: 14px 24px !important;
				min-width: 190px;
				max-width: none;
				box-shadow: none !important;
			}

			.formsubmit.zcwf_button:hover {
				opacity: 0.95;
			}

			.zcwf_lblLeft .zcwf_button {
				font-size: 14px;
				color: #313949;
				border: 1px solid #c0c6cc;
				padding: 10px 16px;
				border-radius: 10px;
				cursor: pointer;
				max-width: none;
				overflow: hidden;
				text-overflow: ellipsis;
				white-space: nowrap;
			}

			input[type="reset"] {
				display: none !important;
			}

			.zcwf_lblLeft .zcwf_tooltip_over {
				position: relative;
			}

			.zcwf_lblLeft .zcwf_tooltip_ctn {
				position: absolute;
				background: #dedede;
				padding: 3px 6px;
				top: 3px;
				border-radius: 4px;
				word-break: break-word;
				min-width: 100px;
				max-width: 150px;
				color: #313949;
				z-index: 100;
			}

			.zcwf_lblLeft .zcwf_ckbox {
				float: left;
			}

			.zcwf_lblLeft .zcwf_file {
				width: 55%;
				box-sizing: border-box;
				float: left;
			}

			.helper-text {
				font-size: 12px;
				color: #5f6b7a;
				margin-top: 10px;
			}

			@media all and (max-width: 600px) {
				#crmWebToEntityForm.zcwf_lblLeft {
					padding: 20px;
				}

				.zcwf_lblLeft .zcwf_col_lab,
				.zcwf_lblLeft .zcwf_col_fld {
					width: 100%;
					float: none !important;
				}

				.zcwf_lblLeft .zcwf_col_lab {
					padding: 0 0 8px 0;
				}

				.formsubmit.zcwf_button {
					width: 100%;
				}
			}
		</style>

		<div class='zcwf_row'>
			<div class='zcwf_col_lab'>
				<label for='Last_Name'>Nombre <span style='color:red;'>*</span></label>
			</div>
			<div class='zcwf_col_fld'>
				<input type='text' id='Last_Name' aria-required='true' aria-label='Last Name' name='Last Name' aria-valuemax='80' maxlength='80'>
				<div class='zcwf_col_help'></div>
			</div>
		</div>

		<div class='zcwf_row'>
			<div class='zcwf_col_lab'>
				<label for='Company'>Nombre de la farmacia <span style='color:red;'>*</span></label>
			</div>
			<div class='zcwf_col_fld'>
				<input type='text' id='Company' aria-required='true' aria-label='Company' name='Company' aria-valuemax='200' maxlength='200'>
				<div class='zcwf_col_help'></div>
			</div>
		</div>

		<div class='zcwf_row'>
			<div class='zcwf_col_lab'>
				<label for='Phone'>Teléfono <span style='color:red;'>*</span></label>
			</div>
			<div class='zcwf_col_fld'>
				<input type='text' id='Phone' aria-required='true' aria-label='Phone' name='Phone' aria-valuemax='30' maxlength='30'>
				<div class='zcwf_col_help'></div>
			</div>
		</div>

		<div class='zcwf_row'>
			<div class='zcwf_col_lab'>
				<label for='Email'>Email</label>
			</div>
			<div class='zcwf_col_fld'>
				<input type='text' ftype='email' autocomplete='false' id='Email' aria-required='false' aria-label='Email' name='Email' aria-valuemax='100' crmlabel='' maxlength='100'>
				<div class='zcwf_col_help'></div>
			</div>
		</div>

		<input type='text' style='display:none;' name='aG9uZXlwb3Q' value=''>

		<div class='zcwf_row'>
			<div class='zcwf_col_lab'></div>
			<div class='zcwf_col_fld'>
				<input type='submit' id='formsubmit' role='button' class='formsubmit zcwf_button' value='Quiero mi demo' aria-label='Quiero mi demo' title='Quiero mi demo'>
				<div class='helper-text'>Te contactaremos en menos de 24 horas.</div>
			</div>
		</div>

		<script>
			function validateEmail7139392000001107011(){
				var form = document.forms['WebToLeads7139392000001107011'];
				var emailFld = form.querySelectorAll('[ftype=email]');
				var i;
				for(i = 0; i < emailFld.length; i++ ) {
					var emailVal = emailFld[i].value;
					if ((emailVal.replace(/^\s+|\s+$/g,'')) .length != 0) {
						var atpos = emailVal.indexOf('@');
						var dotpos = emailVal.lastIndexOf('.');
						if(atpos < 1 || dotpos < atpos + 2 || dotpos + 2 >= emailVal.length) {
							alert('Introduzca una dirección de correo electrónico válida.');
							emailFld[i].focus();
							return false;
						}
					}
				}
				return true;
			}

			function checkMandatory7139392000001107011(){
				var mndFileds = new Array('Company', 'Last Name', 'Phone');
				var fldLangVal = new Array('Nombre de la farmacia', 'Nombre', 'Teléfono');
				for (i = 0; i < mndFileds.length; i++ ) {
					var fieldObj = document.forms['WebToLeads7139392000001107011'][mndFileds[i]];
					if (fieldObj) {
						if(((fieldObj.value).replace(/^\s+|\s+$/g,'')) .length == 0) {
							if (fieldObj.type == 'file') {
								alert('Seleccione un archivo para cargar.');
								fieldObj.focus();
								return false;
							}
							alert(fldLangVal[i] + ' no puede estar vacío.');
							fieldObj.focus();
							return false;
						} else if (fieldObj.nodeName == 'SELECT') {
							if (fieldObj.options[fieldObj.selectedIndex].value == '-None-') {
								alert(fldLangVal[i] + ' no puede ser nulo.');
								fieldObj.focus();
								return false;
							}
						} else if (fieldObj.type == 'checkbox') {
							if (fieldObj.checked == false) {
								alert('Please accept ' + fldLangVal[i]);
								fieldObj.focus();
								return false;
							}
						}
						try {
							if (fieldObj.name == 'Last Name') {
								name = fieldObj.value;
							}
						} catch (e) {}
					}
				}
				if (!validateEmail7139392000001107011()) {
					return false;
				}
				var urlparams = new URLSearchParams(window.location.search);
				if (urlparams.has('service') && (urlparams.get('service') === 'smarturl')) {
					var webform = document.getElementById('webform7139392000001107011');
					var service = urlparams.get('service');
					var smarturlfield = document.createElement('input');
					smarturlfield.setAttribute('type', 'hidden');
					smarturlfield.setAttribute('value', service);
					smarturlfield.setAttribute('name', 'service');
					webform.appendChild(smarturlfield);
				}
				document.querySelector('.crmWebToEntityForm .formsubmit').setAttribute('disabled', true);
			}

			function tooltipShow7139392000001107011(el){
				var tooltip = el.nextElementSibling;
				var tooltipDisplay = tooltip.style.display;
				if (tooltipDisplay == 'none') {
					var allTooltip = document.getElementsByClassName('zcwf_tooltip_over');
					for (i = 0; i < allTooltip.length; i++ ) {
						allTooltip[i].style.display = 'none';
					}
					tooltip.style.display = 'block';
				} else {
					tooltip.style.display = 'none';
				}
			}
		</script>

		<!-- Do not remove this --- Analytics Tracking code starts -->
		<script id='wf_anal' src='https://crm.zohopublic.com/crm/WebFormAnalyticsServeServlet?rid=f4419bcb8cc861212561f9418ffee02184583da37057abe9df8c7a2f8ce42c6dffcc9778cca1cff6b2d950734d8d64bbgidea3eec88ef342980ca37721c5119cd3fbdaedb1091398bb4546a38a9354014eegid0112362bc6c835f87736334adbeff40fbd4dbc64e114dda4001cd0609ce2e0cbgidd04635993de8d8d763dac6b2be4a7f5586f239c4844017495d0f8f568d228541&tw=d7d5fcfbda4026c86098e4bd68266093a7ffaae39dd0cf50acc2b271cfb47446'></script>
		<!-- Do not remove this --- Analytics Tracking code ends -->

	</form>
</div>