Remitir Denuncia a IPS

[date_submit]
[field id="ciudad1"]
[field id="nombre1"]
[field id="nombre2"]
[field id="cedula2"]
[field id="cedula1"]
[field id="domicilio1"]
[field id="domicilio2"]
[field id="ruc2"]
[field id="celular1"]
[field id="celular2"]