{"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 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_1' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Forms & Vaccination Records Request new<\/h2>\n                            <span 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><\/span>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/pages\/1631' 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'><div id=\"field_1_24\"  class=\"gfield gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_35\"  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_1_35\"><h4>Child's Name<\/h4><\/div><fieldset id=\"field_1_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_1_1\"><legend class='gfield_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 no_prefix has_first_name no_middle_name no_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first' >\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='hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_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_1_34\"><legend class='gfield_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 no_prefix no_first_name no_middle_name has_last_name no_suffix gf_name_has_1 ginput_container_name' id='input_1_34'>\n                            \n                            \n                            \n                            <span id='input_1_34_6_container' class='name_last' >\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='hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_15\"  class=\"gfield gfield--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\"><label class='gfield_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--width-quarter gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_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_text\">(Required)<\/span><\/span><\/legend><div id='input_1_14' class='ginput_container ginput_complex'><div class='gfield_date_month ginput_container ginput_container_date' id='input_1_14_1_container'>\n                                            <input type='number'  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='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_1_14_2_container'>\n                                            <input type='number'  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='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_1_14_3_container'>\n                                            <input type='number'  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='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_22\"  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_1_22\"><h4>Check All Forms That Are Needed ($10 Per Form)\n<\/h4><\/div><div id=\"field_1_16\"  class=\"gfield gfield--width-half gf_list_4col gfield_price gfield_price_1_16 gfield_product_1_16 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\"><label class='gfield_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--width-half gfield_price gfield_price_1_19 gfield_product_1_19 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\"><label class='gfield_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--width-half gfield_price gfield_price_1_20 gfield_product_1_20 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\"><label class='gfield_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--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_42\"><legend class='gfield_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'>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 gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_36\"  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_1_36\"><h4>2nd Child's Name (If Applicable)<\/h4><\/div><fieldset id=\"field_1_25\"  class=\"gfield gfield--width-quarter field_sublabel_hidden_label field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\"><legend class='gfield_label gfield_label_before_complex'  >First Name<\/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_1_25'>\n                            \n                            <span id='input_1_25_3_container' class='name_first' >\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='hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_37\"  class=\"gfield gfield--width-quarter field_sublabel_hidden_label field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\"><legend class='gfield_label gfield_label_before_complex'  >Last Name<\/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_1_37'>\n                            \n                            \n                            \n                            <span id='input_1_37_6_container' class='name_last' >\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='hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_26\"  class=\"gfield gfield--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\"><label class='gfield_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--width-quarter field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\"><legend class='gfield_label gfield_label_before_complex'  >Child&#039;s Date of Birth<\/legend><div id='input_1_27' class='ginput_container ginput_complex'><div class='gfield_date_month ginput_container ginput_container_date' id='input_1_27_1_container'>\n                                            <input type='number'  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='screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date' id='input_1_27_2_container'>\n                                            <input type='number'  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='screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date' id='input_1_27_3_container'>\n                                            <input type='number'  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='screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_1_33\"  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_1_33\"><h4>Check All Forms That Are Needed ($10 Per Form)\n<\/h4><\/div><div id=\"field_1_28\"  class=\"gfield gfield--width-half gf_list_4col gfield_price gfield_price_1_28 gfield_product_1_28 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\"><label class='gfield_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--width-half gfield_price gfield_price_1_29 gfield_product_1_29 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\"><label class='gfield_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--width-half gfield_price gfield_price_1_30 gfield_product_1_30 field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\"><label class='gfield_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--width-half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\"><legend class='gfield_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'>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 gsection field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\"><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_1_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_1_38\"><label class='gfield_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--width-half hipaa_forms_phone gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\"><label class='gfield_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 top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \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_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' \/>\n            <input type='hidden' 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=\"162\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><\/form>\n                        <\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-4 fusion-flex-container fusion-parallax-none hundred-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-padding-bottom:100px;--awb-background-image:linear-gradient(180deg, rgba(255,255,255,0.66) 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, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2023\/05\/Topline-logo.png 270w\" sizes=\"(max-width: 960px) 100vw, 270px\" \/><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-last logo-footer\" style=\"--awb-padding-top:30px;--awb-bg-size:cover;--awb-margin-bottom:0px;width:50%;width:calc(50% - ( ( 0 ) * 0.5 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-max-width:300px;--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-3 hover-type-none\"><a class=\"fusion-no-lightbox\" href=\"https:\/\/www.toplinemd.com\/why-topline-md\/\" target=\"_blank\" aria-label=\"TopLine MD-RegisterR_Stacked_Logo_rgb_color\" rel=\"noopener noreferrer\"><img decoding=\"async\" width=\"1576\" height=\"376\" src=\"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png\" alt class=\"img-responsive wp-image-1761\" srcset=\"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-200x48.png 200w, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-400x95.png 400w, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-600x143.png 600w, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-800x191.png 800w, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-1200x286.png 1200w, https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-content\/uploads\/sites\/279\/2026\/04\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png 1576w\" sizes=\"(max-width: 960px) 100vw, 800px\" \/><\/a><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":13,"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-1631","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/pages\/1631","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/users\/13"}],"replies":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/comments?post=1631"}],"version-history":[{"count":0,"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/pages\/1631\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.toplinemd.com\/south-miami-pediatric-partners\/wp-json\/wp\/v2\/media?parent=1631"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}