{"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 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_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <span 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><\/span>\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' 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'><div id=\"field_6_24\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_24\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_6_71\"  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_6_71\"><h3>Child's Name<\/h3><\/div><fieldset id=\"field_6_1\"  class=\"gfield gfield--width-quarter hipaa_forms_first_name gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_1\"><legend class='gfield_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 no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first' >\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='hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_6_34\"  class=\"gfield gfield--width-quarter hipaa_forms_last_name gfield_contains_required field_sublabel_hidden_label field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_34\"><legend class='gfield_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 no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_6_34'>\n                            \n                            \n                            \n                            <span id='input_6_34_6_container' class='name_last' >\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='hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_15\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_15\"><label class='gfield_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--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_14\"><legend class='gfield_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'><div class='gfield_date_month ginput_container ginput_container_date' id='input_6_14_1_container'>\n                                            <input type='number'  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='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_6_14_2_container'>\n                                            <input type='number'  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='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_6_14_3_container'>\n                                            <input type='number'  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='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_6_92\"  class=\"gfield gfield--width-full gf_list_inline gfield_price gfield_price_6_92 gfield_product_6_92 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_92\"><legend class='gfield_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'>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'>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--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_88\"><label class='gfield_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;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;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'>\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' 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='gform_fileupload_rules' id='gfield_upload_rules_6_88'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message validation_message--hidden-on-empty gfield_validation_message gform-ul-reset' id='gform_multifile_messages_6_88'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_6_88'><\/div><\/div><div id=\"field_6_90\"  class=\"gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_90\"><label class='gfield_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;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;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'>\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' 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='gform_fileupload_rules' id='gfield_upload_rules_6_90'>Max. file size: 2 MB, Max. files: 5.<\/span><ul class='validation_message validation_message--hidden-on-empty gfield_validation_message gform-ul-reset' id='gform_multifile_messages_6_90'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_6_90'><\/div><\/div><div id=\"field_6_62\"  class=\"gfield gfield--width-third gfield_price gfield_price_6_62 gfield_product_6_62 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_62\"><label class='gfield_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--width-third gfield_price gfield_price_6_87 gfield_product_6_87 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_87\"><label class='gfield_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--width-third gfield_price gfield_price_6_63 gfield_product_6_63 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_63\"><label class='gfield_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--width-third gfield_price gfield_price_6_86 gfield_product_6_86 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_86\"><label class='gfield_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--width-third gfield_price gfield_price_6_67 gfield_product_6_67 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_67\"><label class='gfield_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--width-third gfield_price gfield_price_6_66 gfield_product_6_66 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_66\"><label class='gfield_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 gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_32\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_6_84\"  class=\"gfield gfield--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_84\"><label class='gfield_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--width-half hipaa_forms_email gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_38\"><label class='gfield_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--width-full gfield_price gfield_price_6_83 gfield_product_6_83 gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_83\"><label class='gfield_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 class=\"spacer gfield\" style=\"grid-column: span 6;\"><\/div><div id=\"field_6_95\"  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_6_95\"><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--width-full gfield_price gfield_price_6_ gfield_total gfield_total_6_ field_sublabel_below field_description_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" data-js-reload=\"field_6_44\"><label class='gfield_label' for='input_6_44' >Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input 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--width-full hipaa_forms_office_location field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_6_94\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_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 id=\"field_6_96\"  class=\"gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_96\"><label class='gfield_label' for='input_6_96' >Phone<\/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><\/div>\n        <div class='gform_footer top_label'>  <input type='hidden' name='gform_ajax' value='form_id=6&amp;title=&amp;description=1&amp;tabindex=0' \/>\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_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_6' value='' \/>\n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"106\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div>\n                <iframe 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                <script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );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'), 10) + 100;if(is_form){jQuery('#gform_wrapper_6').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_6').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_6').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_6').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_6').val();gformInitSpinner( 6, 'https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery(document).trigger('gform_page_loaded', [6, current_page]);window['gf_submitting_6'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = 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);\n<\/script><\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":86,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1832","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/pages\/1832","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/users\/86"}],"replies":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/comments?post=1832"}],"version-history":[{"count":0,"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/pages\/1832\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.toplinemd.com\/pediatric-pros\/wp-json\/wp\/v2\/media?parent=1832"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}