We are sorry to see you go.
At Fairhope Pediatrics we strive to provide exemplary care for every patient. Can you please take a moment to let us know about your experience?
What is the patient's name and date of birth?
Name
(Required)
DOB
(Required)
MM slash DD slash YYYY
Please tell us why you are transferring to another pediatrician or other primary care provider.
(Required)
Select...
My child has transitioned to an adult doctor
My insurance changed and you are no longer in network with my plan
I do not want to vaccinate my child according to CDC guidelines
I do not want to complete CHADIS questionnaires
Poor experience
Other
Please explain.
(Required)
Name
This field is for validation purposes and should be left unchanged.
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