{"id":1599,"date":"2021-09-21T21:18:50","date_gmt":"2021-09-21T21:18:50","guid":{"rendered":"https:\/\/www.toplinemd.com\/gables-pediatrics\/?page_id=1599"},"modified":"2023-09-12T07:37:47","modified_gmt":"2023-09-12T07:37:47","slug":"forms-request","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/gables-pediatrics\/forms-request\/","title":{"rendered":"Forms Request"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:40px;--awb-padding-bottom:25px;--awb-background-color:#f5f5f5;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#444444;--awb-margin-bottom:20px;\"><h1 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:48;line-height:1;\">Forms &amp; Vaccination Records Request<\/h1><\/div><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme' id='gform_wrapper_10' >\n                        <div class='gform_heading'>\n                            <span class='gform_description'><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/gables-pediatrics\/wp-json\/wp\/v2\/pages\/1599' novalidate> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform_body gform-body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_10_3\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_3\"><h4>Child's Name<\/h4><\/div><div id=\"field_10_6\"  class=\"gfield gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_6\"><label class='gfield_label' for='input_10_6' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_10_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_7\"  class=\"gfield gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_7\"><label class='gfield_label' for='input_10_7' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_10_7' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_8\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_8\"><label class='gfield_label' for='input_10_8' >School Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_10_8' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_9\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_9\"><legend class='gfield_label gfield_label_before_complex'  >Child&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_10_9' class='ginput_container ginput_complex'><div class='gfield_date_month ginput_container ginput_container_date' id='input_10_9_1_container'>\n                                            <input type='number'  name='input_9[]' id='input_10_9_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_10_9_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_10_9_2_container'>\n                                            <input type='number'  name='input_9[]' id='input_10_9_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_10_9_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_10_9_3_container'>\n                                            <input type='number'  name='input_9[]' id='input_10_9_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_10_9_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_10\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_10\"><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_10_13\"  class=\"gfield gfield--width-half gfield_price gfield_price_10_13 gfield_product_10_13 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_13\"><label class='gfield_label' for='input_10_13' >School Form (Yellow\/Blue Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_10_13' class='large gfield_select'  aria-describedby=\"gfield_description_10_13\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_13'>(Form 680\/3040)<\/div><\/div><div id=\"field_10_15\"  class=\"gfield gfield--width-half gfield_price gfield_price_10_15 gfield_product_10_15 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_15\"><label class='gfield_label' for='input_10_15' >Athletic Form (All Schools)<\/label><div class='ginput_container ginput_container_select'><select name='input_15' id='input_10_15' class='large gfield_select'  aria-describedby=\"gfield_description_10_15\"   aria-invalid=\"false\" ><option value='Form EL2 - Qty: 0|0' >Form EL2 - Qty: 0<\/option><option value='Form EL2 - Qty: 1|10' >Form EL2 - Qty: 1<\/option><option value='Form EL2 - Qty: 2|20' >Form EL2 - Qty: 2<\/option><option value='Form EL2 - Qty: 3|30' >Form EL2 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_15'>(Form EL2)<\/div><\/div><fieldset id=\"field_10_16\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_16\"><legend class='gfield_label gfield_label_before_complex'  >Vaccination History (Free Of Charge)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_16'><div class='gchoice gchoice_10_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Vaccination History'  id='choice_10_16_1'   aria-describedby=\"gfield_description_10_16\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_16_1' id='label_10_16_1'>Vaccination History<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_10_16'>(NOT sufficient for SCHOOL ENTRY)<\/div><\/fieldset><div id=\"field_10_25\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_25\"><h4>2nd Child's Name (If Applicable)<\/h4><\/div><div id=\"field_10_21\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_21\"><label class='gfield_label' for='input_10_21' >First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_10_21' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_22\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_22\"><label class='gfield_label' for='input_10_22' >Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_10_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_23\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_23\"><label class='gfield_label' for='input_10_23' >School Name<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_10_23' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_24\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_24\"><legend class='gfield_label gfield_label_before_complex'  >Child&#039;s Date of Birth<\/legend><div id='input_10_24' class='ginput_container ginput_complex'><div class='gfield_date_month ginput_container ginput_container_date' id='input_10_24_1_container'>\n                                            <input type='number'  name='input_24[]' id='input_10_24_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_10_24_1' class='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_10_24_2_container'>\n                                            <input type='number'  name='input_24[]' id='input_10_24_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_10_24_2' class='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_10_24_3_container'>\n                                            <input type='number'  name='input_24[]' id='input_10_24_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_10_24_3' class='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_20\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_20\"><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_10_26\"  class=\"gfield gfield--width-half gfield_price gfield_price_10_26 gfield_product_10_26 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_26\"><label class='gfield_label' for='input_10_26' >School Form (Yellow\/Blue Form)<\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_10_26' class='large gfield_select'  aria-describedby=\"gfield_description_10_26\"   aria-invalid=\"false\" ><option value='Yellow\/Blue Form - Qty: 0|0' >Yellow\/Blue Form - Qty: 0<\/option><option value='Yellow\/Blue Form - Qty: 1|10' >Yellow\/Blue Form - Qty: 1<\/option><option value='Yellow\/Blue Form - Qty: 2|20' >Yellow\/Blue Form - Qty: 2<\/option><option value='Yellow\/Blue Form - Qty: 3|30' >Yellow\/Blue Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_26'>(Form 680\/3040)<\/div><\/div><div id=\"field_10_28\"  class=\"gfield gfield--width-half gfield_price gfield_price_10_28 gfield_product_10_28 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_28\"><label class='gfield_label' for='input_10_28' >Athletic Form (All Schools)<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_10_28' class='large gfield_select'  aria-describedby=\"gfield_description_10_28\"   aria-invalid=\"false\" ><option value='Form EL2 - Qty: 0|0' >Form EL2 - Qty: 0<\/option><option value='Form EL2 - Qty: 1|10' >Form EL2 - Qty: 1<\/option><option value='Form EL2 - Qty: 2|20' >Form EL2 - Qty: 2<\/option><option value='Form EL2 - Qty: 3|30' >Form EL2 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_10_28'>(Form EL2)<\/div><\/div><fieldset id=\"field_10_29\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_29\"><legend class='gfield_label gfield_label_before_complex'  >Vaccination History (Free Of Charge)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_10_29'><div class='gchoice gchoice_10_29_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_29.1' type='checkbox'  value='Vaccination History'  id='choice_10_29_1'   aria-describedby=\"gfield_description_10_29\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_29_1' id='label_10_29_1'>Vaccination History<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_10_29'>(NOT sufficient for SCHOOL ENTRY)<\/div><\/fieldset><div id=\"field_10_31\"  class=\"gfield gfield--width-half hipaa_forms_email gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_31\"><label class='gfield_label' for='input_10_31' >Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_10_31' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_32\"  class=\"gfield gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_32\"><label class='gfield_label' for='input_10_32' >Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_10_32' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_34\"  class=\"gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_34\"><label class='gfield_label' for='input_10_34' >Delivery Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_10_34' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Email' >Email<\/option><option value='Pick Up In Person (Coral Gables Office)' >Pick Up In Person (Coral Gables Office)<\/option><option value='Pick Up In Person (Doral Office)' >Pick Up In Person (Doral Office)<\/option><\/select><\/div><\/div><div id=\"field_10_35\"  class=\"gfield gfield--width-half gfield_price gfield_price_10_35 gfield_product_10_35 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_10_35\"><label class='gfield_label' for='input_10_35' >Delivery Speed<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_10_35' class='large gfield_select'     aria-invalid=\"false\" ><option value='Standard (Ready in 5 Business Days. No Extra Cost)|0' >Standard (Ready in 5 Business Days. No Extra Cost)<\/option><option value='Rush (Ready in 2 Business Days. Adds $5 to Order|5' >Rush (Ready in 2 Business Days. 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( ( 0 ) * 0.5 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"270\" height=\"100\" title=\"270x100px\" src=\"https:\/\/www.toplinemd.com\/gables-pediatrics\/wp-content\/uploads\/sites\/253\/2021\/09\/270x100px.png\" alt class=\"img-responsive wp-image-1642\" srcset=\"https:\/\/www.toplinemd.com\/gables-pediatrics\/wp-content\/uploads\/sites\/253\/2021\/09\/270x100px-200x74.png 200w, https:\/\/www.toplinemd.com\/gables-pediatrics\/wp-content\/uploads\/sites\/253\/2021\/09\/270x100px.png 270w\" sizes=\"(max-width: 960px) 100vw, 270px\" \/><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-last logo-footer\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-margin-bottom:0px;width:50%;width:calc(50% - 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