{"id":1631,"date":"2023-06-08T08:12:37","date_gmt":"2023-06-08T08:12:37","guid":{"rendered":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/?page_id=1631"},"modified":"2023-09-17T20:34:42","modified_gmt":"2023-09-17T20:34:42","slug":"school-form-request","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/school-form-request\/","title":{"rendered":"School Form Request"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container fusion-parallax-none 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:5%;--awb-padding-bottom:6%;--awb-background-image:url(&quot;https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2023\/09\/School-Form-Request.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1289.6px;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_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:40px;--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-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#ffffff;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:70px;\"><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:70;line-height:0.86;\">Forms &amp; Vaccination Records Request<\/h1><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 hundred-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:0px;--awb-padding-right:0px;--awb-padding-bottom:0px;--awb-padding-left:0px;--awb-margin-top:0px;--awb-background-color:#ffffff;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;--awb-margin-top:-65px;--awb-margin-bottom:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-section-separator section-separator rounded-split fusion-section-separator-1 rounded-split-separator\" style=\"--awb-spacer-height:71px;--awb-svg-margin-left:0;--awb-svg-margin-right:0;\"><div class=\"fusion-section-separator-svg\"><div class=\"rounded-split bottom\" style=\"background-color:#ffffff;\"><\/div><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 fusion-flex-container 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-background-image:linear-gradient(180deg, #ffffff 0%,#f5f5f5 100%);--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1289.6px;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_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:40px;--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_1' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Forms & Vaccination Records Request new<\/h2>\n                            <p class='gform_description'><h4>School Forms, Athletic Forms & Vaccination Records<\/h4>\r\n<p>To request forms, please fill out the information below and make a payment. Your forms will be available between 1 to 5 business days from the date of request, depending on your selected delivery speed.<\/p>\r\n<p>Please note you will NOT be contacted notifying you that your forms are ready.<\/p><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/pages\/1631' data-formid='1' 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_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_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_1_35\" 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>Child's Name<\/h4><\/div><fieldset id=\"field_1_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_text\">(Required)<\/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_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_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_1_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_text\">(Required)<\/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_1_34'>\n                            \n                            \n                            \n                            <span id='input_1_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_1_34_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_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_1_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_1_15'>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_15' id='input_1_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_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_text\">(Required)<\/span><\/span><\/legend><div id='input_1_14' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_14_1_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_1_14_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_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_1_14_2_container'>\n                                            <input type='number' maxlength='2' name='input_14[]' id='input_1_14_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_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_1_14_3_container'>\n                                            <input type='number' maxlength='4' name='input_14[]' id='input_1_14_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_14_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_22\" 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)\n<\/h4><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gf_list_4col gfield_price gfield_price_1_16 gfield_product_1_16 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>School Form (Yellow\/Blue Form)(Form 680\/3040)<\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'     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><div id=\"field_1_19\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_1_19 gfield_product_1_19 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_19'>Athletic Form (Archdiocese\/Catholic Parochial School)<\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'     aria-invalid=\"false\" ><option value='|0' >Athletic Form - Qty: 0<\/option><option value='|10' >Athletic Form - Qty: 1<\/option><option value='|20' >Athletic Form - Qty: 2<\/option><option value='|30' >Athletic Form - Qty: 3<\/option><\/select><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_1_20 gfield_product_1_20 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Athletic Form (All Other Schools)(Form EL2)<\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='large gfield_select'     aria-invalid=\"false\" ><option value='|0' >Form EL2 - Qty: 0<\/option><option value='|10' >Form EL2 - Qty: 1<\/option><option value='|20' >Form EL2 - Qty: 2<\/option><option value='|30' >Form EL2 - Qty: 3<\/option><\/select><\/div><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half 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' >Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_42'><div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)'  id='choice_1_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_23\" 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_1_36\" 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>2nd Child's Name (If Applicable)<\/h4><\/div><fieldset id=\"field_1_25\" class=\"gfield gfield--type-name gfield--width-quarter 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<\/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_1_25'>\n                            \n                            <span id='input_1_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_1_25_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_25_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_1_37\" class=\"gfield gfield--type-name gfield--width-quarter 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<\/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_1_37'>\n                            \n                            \n                            \n                            <span id='input_1_37_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.6' id='input_1_37_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_37_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_1_26\" 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_1_26'>School Name<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_27\" 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_1_27' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_1_27_1_container'>\n                                            <input type='number' maxlength='2' name='input_27[]' id='input_1_27_1' value=''   aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_1_27_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_1_27_2_container'>\n                                            <input type='number' maxlength='2' name='input_27[]' id='input_1_27_2' value=''   aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_1_27_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_1_27_3_container'>\n                                            <input type='number' maxlength='4' name='input_27[]' id='input_1_27_3' value=''   aria-required='false'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                            <label for='input_1_27_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_33\" 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)\n<\/h4><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gf_list_4col gfield_price gfield_price_1_28 gfield_product_1_28 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_28'>School Form (Yellow\/Blue Form)(Form 680\/3040)<\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='large gfield_select'     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><div id=\"field_1_29\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_1_29 gfield_product_1_29 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_29'>Athletic Form (Archdiocese\/Catholic Parochial School)<\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_1_29' class='large gfield_select'     aria-invalid=\"false\" ><option value='Athletic Form - Qty: 0|0' >Athletic Form - Qty: 0<\/option><option value='Athletic Form - Qty: 1|10' >Athletic Form - Qty: 1<\/option><option value='Athletic Form - Qty: 2|20' >Athletic Form - Qty: 2<\/option><option value='Athletic Form - Qty: 3|30' >Athletic Form - Qty: 3<\/option><\/select><\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-product gfield--input-type-select gfield--width-half gfield_price gfield_price_1_30 gfield_product_1_30 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_30'>Athletic Form (All Other Schools)(Form EL2)<\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_1_30' class='large gfield_select'     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><fieldset id=\"field_1_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-half 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' >Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_43'><div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)'  id='choice_1_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Vaccination History (Free Of Charge)(NOT sufficient for SCHOOL ENTRY)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_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_1_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_1_38'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_38' id='input_1_38' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_39\" 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_1_39'>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_39' id='input_1_39' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='Herk9u6xfS0jrt9zCnYmhkLS4vhCiQwuwSrf0nKEpl2TFP6iYFIbxd\/EzDCJN\/DcusF9xaGhYiBZOCOVEEqDzXGDJz2o9aKmdzGqDISIbTB+yJk=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \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=\"32\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_1').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_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').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_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) 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0%,rgba(255,255,255,0.26) 100%),url(https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2023\/09\/CTA-section.jpg);;--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"width:calc( 100% + 0px ) !important;max-width:calc( 100% + 0px ) !important;margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><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-blend:overlay;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:120px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-section-separator section-separator rounded-split fusion-section-separator-2 rounded-split-separator\" style=\"--awb-spacer-height:71px;--awb-svg-margin-left:0px;--awb-svg-margin-right:0px;--awb-svg-margin-left-medium:0px;--awb-svg-margin-right-medium:0px;--awb-svg-margin-left-small:0px;--awb-svg-margin-right-small:0px;\"><div class=\"fusion-section-separator-svg\"><div class=\"rounded-split top\" style=\"background-color:#f5f5f5;\"><\/div><\/div><div class=\"fusion-section-separator-spacer\"><div class=\"fusion-section-separator-spacer-height\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-flex-column padding-null\" style=\"--awb-padding-right:13%;--awb-padding-left:13%;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-text fusion-text-1\"><p style=\"text-align: center; color: #d87761; font-size: 48px; line-height: 1;\">Request an <strong>appointment<\/strong><\/p>\n<\/div><div class=\"fusion-image-element\" style=\"text-align:center;--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"48\" height=\"54\" title=\"Layer 5\" src=\"https:\/\/www.toplinemd.com\/wp-content\/uploads\/sites\/279\/2019\/08\/Layer-5.png\" alt class=\"img-responsive wp-image-1251\"\/><\/span><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:18px;width:100%;\"><\/div><div class=\"fusion-text fusion-text-2\"><p style=\"text-align: center;\">Have a question about our practice or want to schedule an appointment?<br \/>\nReach out and speak with a member of our team.<\/p>\n<\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:15px;width:100%;\"><\/div><div style=\"text-align:center;\"><a class=\"fusion-button button-flat button-xlarge button-default fusion-button-default button-1 fusion-button-default-span fusion-button-default-type\" style=\"--button_text_transform:uppercase;\" target=\"_self\" href=\"tel:+13056655808\"><span class=\"fusion-button-text awb-button__text awb-button__text--default\">Call Now<\/span><\/a><\/div><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-5 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns logos-footer\" 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:10px;--awb-padding-bottom:0px;--awb-padding-left:60px;--awb-background-color:#f0f3f6;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-first logo-footer\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-margin-bottom:0px;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );margin-right: 0px;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-2 hover-type-none\"><img decoding=\"async\" width=\"270\" height=\"100\" title=\"Topline-logo\" src=\"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2023\/05\/Topline-logo.png\" alt class=\"img-responsive wp-image-1618\" srcset=\"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2023\/05\/Topline-logo-200x74.png 200w, 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