{"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;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><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>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_10' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/gables-pediatrics\/wp-json\/wp\/v2\/pages\/1599' data-formid='10' novalidate> \r\n <input type=\"hidden\" class=\"gforms-pum\" value=\"{&quot;closepopup&quot;:false,&quot;closedelay&quot;:0,&quot;openpopup&quot;:false,&quot;openpopup_id&quot;:0}\" \/>\n                        <div class='gform-body gform_body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_10_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Child's Name<\/h4><\/div><div id=\"field_10_6\" class=\"gfield gfield--type-text gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-text gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-text gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-date gfield--input-type-datefield gfield--width-quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-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 gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_10_9_1_container'>\n                                            <input type='number' maxlength='2' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_10_9_2_container'>\n                                            <input type='number' maxlength='2' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_10_9_3_container'>\n                                            <input type='number' maxlength='4' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_10\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_10_13\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_10_13 gfield_product_10_13 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_10_15 gfield_product_10_15 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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 gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-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' class='gform-field-label gform-field-label--type-inline'>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--type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>2nd Child's Name (If Applicable)<\/h4><\/div><div id=\"field_10_21\" class=\"gfield gfield--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-date gfield--input-type-datefield gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Date of Birth<\/legend><div id='input_10_24' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_10_24_1_container'>\n                                            <input type='number' maxlength='2' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_10_24_2_container'>\n                                            <input type='number' maxlength='2' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_10_24_3_container'>\n                                            <input type='number' maxlength='4' 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='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_20\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4>Check All Forms That Are Needed ($10 Per Form)<\/h4><\/div><div id=\"field_10_26\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_10_26 gfield_product_10_26 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_10_28 gfield_product_10_28 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-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' class='gform-field-label gform-field-label--type-inline'>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--type-text gfield--width-half hipaa_forms_email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-phone gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_10_35 gfield_product_10_35 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-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. Adds $5 to Order<\/option><\/select><\/div><\/div><div id=\"field_10_19\" class=\"gfield gfield--type-total gfield--width-full gfield_price gfield_price_10_ gfield_total gfield_total_10_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_10_19'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_19' id='input_10_19' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_10' \/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_10_37\" class=\"gfield gfield--type-select gfield--width-full hipaa_forms_office_location field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_10_37'>Office Location<\/label><div class='ginput_container ginput_container_select'><select name='input_37' id='input_10_37' class='large gfield_select'     aria-invalid=\"false\" ><option value='forms@gablespediatrics.com' selected='selected'>Gables Pediatrics<\/option><\/select><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'>  \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_10' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_10' id='gform_theme_10' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_10' id='gform_style_settings_10' value='[]' \/>\n            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