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Office forms »

School Forms

Please fill out this form as completely as possible. It will be sent securely to our office.

Email

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PAYMENT REQUIRED

Payment is required to receive your form(s), and will be collected after you provide the necessary information. If payment is not completed, your request will not be processed.

$10 for first 1-2 pages
$5 for each additional page
$25 for a custom letter

Select Forms(Required)

Select the form(s) to be completed. Check all that apply.

Activity Tolerance Form

Child Medical Report (Daycare)

Chronic Condition Statement

Diet Prescription Form

Medication Form

Other School Form

Custom Letter

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F1

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F2

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F3

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F4

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F5

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F8

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Min Adjust

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Pages

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Today

MM slash DD slash YYYY

Other School Form

Upload Form

Max. file size: 512 MB.

If the form is available as a PDF, please upload it here.

Number of Pages(Required)

Form Description or Address(Required)

Please describe the form and provide a web address where it can be found online (unless you have it available to upload.)

Custom Letter

Description of Custom Letter(Required)

Total Fee

Student

Full Name(Required)

Date of Birth(Required)

Age(Required)

Name of School(Required)

School Year(Required)

For example, 2025-2026

Grade(Required)

Name of Teacher

Student Weight(Required)

Known Allergies(Required)

Drug, food, or other allergies. If there are no known allergies, type "None".

Parent/Guardian

Name of Parent/Guardian(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address City State Zip Code

Activity Tolerance Form

Diagnosis(Required)

Duration(Required)

How long will the restrictions be needed?

Chronic Condition Statement

Chronic Condition or Diagnosis(Required)

ICD-10 Code

If known

Specialists(Required)

What specialists are being seen? How often?

Additional Notes

Parent Signature(Required)

Diet Prescription Form

Diagnosis(Required)

Food to Omit

Foods to Substitute

Food to Omit

Foods to Substitute

Other Diet Modifications

Medication Form

Known Drug Allergies(Required)

No

Yes

Drug Allergies(Required)

Medication Type(Required)

Prescription (Rx)

Non-Prescription (OTC)

Medication Name(Required)

Dosage(Required)

mg/mL/units

Route(Required)

oral/inhaler/injection

Frequency(Required)

time(s) given and how often

Start Date(Required)

MM slash DD slash YYYY

Stop Date(Required)

MM slash DD slash YYYY

Reason for Taking Medication(Required)

Special Considerations

Self-Medication(Required)

Is self-medication permitted and recommended?

Yes

No

Kept On Person(Required)

Do you recommend this medication be kept “on person” by the student?

Yes

No

Parent Signature(Required)

I authorize the school Nurse, the registered nurse (RN) or licensed practical nurse (LPN), to administer or to delegate to unlicensed school personnel the task of assisting my child in taking the above medication in accordance with the administrative code practice rules. I understand that additional parent/prescriber signed statements will be necessary if the dosage of medication is changed.

Parent Signature (Self-Medication)(Required)

I authorize and recommend self-medication by my child for the above medication. I also affirm that he/she has been instructed in proper self administration of the prescribed medication by his/her attending physician. I shall indemnify and hold harmless the school, the agents of the school, and the local board of education against any claims that may arise relating to my child’s self-administration of prescribed medication(s).

Form Processing Fee Required

The fee noted below must be paid to complete processing. Forms submitted without this fee will be discarded. See payment instructions on the next page.

Processing Fee

Acknowledgement(Required)

I acknowledge that I must pay the processing fee for the form(s) to be completed. I understand it may require up to 72 business hours for completion.

Connect With Us

Use the Patient Portal to message the clinic staff, schedule appointments, and request medication refills. You can also view your upcoming appointments, medications, lab results, health history, and more.

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Fairhope Pediatrics

19087-B Greeno Road
Fairhope, AL 36532

Phone
(251) 928-5568

Fax
(251) 928-2605

Email
info@fairhopepeds.com

Map & Directions »

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Office Hours

Call us to schedule an appointment.

Monday - Friday
8:00 am - 5:00 pm
Closed for lunch 12:00 pm - 1:30 pm

Saturday
8:00 am - 12:00 pm

We are required to report visits outside of normal business hours to your insurance provider. Appointments scheduled before 8am, after 5pm, and on Saturdays will incur an additional fee, which may be applied to your copay, coinsurance, or annual deductible.

By Appointment Only

To help us keep your children and other patients healthy, we are not accepting walk-ins at this time.

After-hours Care

If your child’s illness or injury is life-threatening, call 911.

Otherwise, call our office at any time to speak with a nurse.

After-Hours Nurse
(251) 928-5568

Poison Control Hotline
1 (800) 222-1222

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