{"id":1832,"date":"2025-03-31T04:50:34","date_gmt":"2025-03-31T09:50:34","guid":{"rendered":"https:\/\/www.toplinemd.com\/pediatric-pros\/?page_id=1832"},"modified":"2025-03-31T07:44:50","modified_gmt":"2025-03-31T12:44:50","slug":"request-school-forms","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/pediatric-pros\/request-school-forms\/","title":{"rendered":"Request School Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:right center;--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-min-height:400px;--awb-background-image:url(&quot;https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/uploads\/sites\/120\/2020\/11\/FAQ-Header-background-1024x213.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-padding-top:20px;--awb-padding-bottom:20px;--awb-bg-color:rgba(54,180,229,0.4);--awb-bg-color-hover:rgba(54,180,229,0.4);--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-title-center fusion-title-text fusion-title-size-one fusion-animated\" style=\"--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:40px;\" data-animationType=\"fadeInUp\" data-animationDuration=\"0.5\" data-animationOffset=\"top-into-view\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;text-transform:uppercase;font-size:1em;--fontSize:40;line-height:1.15;\">Request School Forms<\/h1><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container has-pattern-background has-mask-background 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-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-bottom:15px;width:100%;\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container has-pattern-background has-mask-background 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-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_2 1_2 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:50%;--awb-margin-top-large:0px;--awb-spacing-right-large:3.84%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:3.84%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-menu-anchor\" id=\"school-camp-request-forms\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><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_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><h4>To request school and\/or vaccine form(s), please fill out the information below and make a payment. Please allow our office up to 48 BUSINESS hours to complete your request.<\/h4><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/pediatric-pros\/wp-json\/wp\/v2\/pages\/1832#gf_6' data-formid='6' 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_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_96\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_96'>X\/Twitter<\/label><div class='ginput_container'><input name='input_96' id='input_6_96' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_6_96'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_6_24\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_6_71\" 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\"  ><h3>Child's Name<\/h3><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_6_34\" class=\"gfield gfield--type-name gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_6_34'>\n                            \n                            \n                            \n                            <span id='input_6_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_6_34_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_34_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_15\" 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_6_15'>School Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_6_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_14\" 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_asterisk\">*<\/span><\/span><\/legend><div id='input_6_14' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_6_14_1_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_6_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_6_14_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_6_14_2_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_6_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_6_14_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_6_14_3_container'>\n                                            <input type='number' maxlength='4' name='input_14[]' id='input_6_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_6_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_6_92\" class=\"gfield gfield--type-product gfield--type-choice gfield--input-type-radio gfield--width-full gf_list_inline gfield_price gfield_price_6_92 gfield_product_6_92 field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Upload School Forms<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_6_92'>\n\t\t\t<div class='gchoice gchoice_6_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Yes|20'  id='choice_6_92_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_6_92\"   \/>\n\t\t\t\t\t<label for='choice_6_92_0' id='label_6_92_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_6_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='No|0'  id='choice_6_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_6_92_1' id='label_6_92_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_6_92'>$20 For School Forms Upload<\/div><\/fieldset><div id=\"field_6_88\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_6_88'>Upload School Forms Files<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_6_88' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_6_88&quot;,&quot;container&quot;:&quot;gform_multifile_upload_6_88&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_6_88&quot;,&quot;filelist&quot;:&quot;gform_preview_6_88&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/?gf_page=c9ec85876ce8f39&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;2560000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:6,&quot;field_id&quot;:88,&quot;_gform_file_upload_nonce_6_88&quot;:&quot;75c55ec32a&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_6_88&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_6_88' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_6_88' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_6_88\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_88'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_6_88'><\/ul> <div id='gform_preview_6_88' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_6_90\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_6_90'>Upload Medication or Allergy Forms<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_6_90' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_6_90&quot;,&quot;container&quot;:&quot;gform_multifile_upload_6_90&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_6_90&quot;,&quot;filelist&quot;:&quot;gform_preview_6_90&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/?gf_page=c9ec85876ce8f39&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.toplinemd.com\\\/pediatric-pros\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;2560000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:6,&quot;field_id&quot;:90,&quot;_gform_file_upload_nonce_6_90&quot;:&quot;a80db48aab&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;5&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_6_90&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_6_90' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_6_90' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_6_90\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_90'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_6_90'><\/ul> <div id='gform_preview_6_90' class='ginput_preview_list'><\/div><\/div><\/div><div id=\"field_6_62\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_62 gfield_product_6_62 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_62'>School Form 3040 (Yellow)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_6_62' class='large gfield_select'  aria-describedby=\"gfield_description_6_62\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Form 3040 - Qty: 0|0' >Form 3040 - Qty: 0<\/option><option value='Form 3040  - Qty: 1|5' >Form 3040  - Qty: 1<\/option><option value='Form 3040  - Qty: 2|10' >Form 3040  - Qty: 2<\/option><option value='Form 3040  - Qty: 3|15' >Form 3040  - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_62'>$5 for Form 3040<\/div><\/div><div id=\"field_6_87\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_87 gfield_product_6_87 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_87'>School Form 680 (Blue)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_87' id='input_6_87' class='large gfield_select'  aria-describedby=\"gfield_description_6_87\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Form 680 - Qty: 0|0' >Form 680 - Qty: 0<\/option><option value='Form 680  - Qty: 1|5' >Form 680  - Qty: 1<\/option><option value='Form 680  - Qty: 2|10' >Form 680  - Qty: 2<\/option><option value='Form 680  - Qty: 3|15' >Form 680  - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_87'>$5 for Form 680<\/div><\/div><div id=\"field_6_63\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_63 gfield_product_6_63 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_63'>Sports Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_63' id='input_6_63' class='large gfield_select'  aria-describedby=\"gfield_description_6_63\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Form EL2 - Qty: 0|0' >Form EL2 - Qty: 0<\/option><option value='Form EL2 - Qty: 1|20' >Form EL2 - Qty: 1<\/option><option value='Form EL2 - Qty: 2|40' >Form EL2 - Qty: 2<\/option><option value='Form EL2 - Qty: 3|60' >Form EL2 - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_63'>$20 for Form EL2<\/div><\/div><div id=\"field_6_86\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_86 gfield_product_6_86 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_86'>Vaccination History\/College Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_86' id='input_6_86' class='large gfield_select'  aria-describedby=\"gfield_description_6_86\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Vaccination History\/College - Qty: 0|0' >Vaccination History\/College - Qty: 0<\/option><option value='Vaccination History\/College - Qty: 1|5' >Vaccination History\/College - Qty: 1<\/option><option value='Vaccination History\/College - Qty: 2|10' >Vaccination History\/College - Qty: 2<\/option><option value='Vaccination History\/College - Qty: 3|15' >Vaccination History\/College - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_86'>$5 for VHC Form <br><span>&nbsp;<\/span><\/div><\/div><div id=\"field_6_67\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_67 gfield_product_6_67 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_67'>Over the Counter Medication Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_67' id='input_6_67' class='large gfield_select'  aria-describedby=\"gfield_description_6_67\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='OTC Medication Form - Qty: 0|0' >OTC Medication Form - Qty: 0<\/option><option value='OTC Medication Form - Qty: 1|5' >OTC Medication Form - Qty: 1<\/option><option value='OTC Medication Form - Qty: 2|10' >OTC Medication Form - Qty: 2<\/option><option value='OTC Medication Form - Qty: 3|15' >OTC Medication Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_67'>$5 for OTC Meds Form\n*Must upload form to be filled in<\/div><\/div><div id=\"field_6_66\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-third gfield_price gfield_price_6_66 gfield_product_6_66 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_66'>Allergy &amp; Rx Meds Form<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_66' id='input_6_66' class='large gfield_select'  aria-describedby=\"gfield_description_6_66\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Allergy &amp; Rx Meds Form - Qty: 0|0' >Allergy &amp; Rx Meds Form - Qty: 0<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 1|10' >Allergy &amp; Rx Meds Form - Qty: 1<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 2|20' >Allergy &amp; Rx Meds Form - Qty: 2<\/option><option value='Allergy &amp; Rx Meds Form - Qty: 3|30' >Allergy &amp; Rx Meds Form - Qty: 3<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_6_66'>$10 for Allergy & Rx Meds Form\n*Must upload form to be filled in<\/div><\/div><div id=\"field_6_32\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_6_84\" 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_6_84'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_84' id='input_6_84' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_38\" class=\"gfield gfield--type-email 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_6_38'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_38' id='input_6_38' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_6_83\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-full gfield_price gfield_price_6_83 gfield_product_6_83 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_6_83'>Delivery Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_6_83' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Pick Up|0' >Pick Up<\/option><option value='Email|20' >Email<\/option><\/select><\/div><\/div><div id=\"field_6_95\" 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\"  ><span>For a $20 convenience fee, the forms may be emailed to you. <\/span>\n<span class=\"scanned-version\">Please ensure that your school will accept a scanned version of the original form. Some schools require originals.<\/span><\/div><div id=\"field_6_44\" class=\"gfield gfield--type-total gfield--width-full gfield_price gfield_price_6_ gfield_total gfield_total_6_ 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_6_44'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_44' id='input_6_44' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_6' \/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_6_94\" 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_6_94'>Office Location<\/label><div class='ginput_container ginput_container_select'><select name='input_94' id='input_6_94' class='large gfield_select'     aria-invalid=\"false\" ><option value='PPAFORMS@femwell.com' selected='selected'>Pediatric Pros<\/option><\/select><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'>  <input type='hidden' name='gform_ajax' value='form_id=6&amp;title=&amp;description=1&amp;tabindex=0&amp;theme=gravity-theme&amp;styles=[]&amp;hash=b70651823386c2cb161f0d6b749666f0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_6' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_6' id='gform_theme_6' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_6' id='gform_style_settings_6' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='nZ6RWB11j\/cFP9vMoPVTt2dbsXWiyiV\/x0HLdS8ue47PQcQv++iSBOpo0EfFLB7hpwM1qwViF\/kbSO+UblO9x\/9eQ4cVEyWxkmBdOFkmfgCydxk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='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' 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style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_6' id='gform_ajax_frame_6' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_6').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_6');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_6').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 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