Forms & Policies

Effective October 1, 2016, Dothan Pediatric Clinic will charge for the completion of forms when not completed at the time of service.

As an alternative you can use your patient portal account to request forms at NO CHARGE. If you do not have a patient portal account, please call us at (334) 793-1881 ext 2699.

 

Form Cost Time for Completion

FMLA

$20

10 days

School Medication Forms

$10

10 days

School Excuses for Past Visits

$10

10 days

Letters

$10

10 days

Miscellaneous Forms

$10

10 days

Patient Profile for Social Security

$5

1 day

LIHEAP - Power Assistance

$5

1 day

 

An additional $20 will be charged for forms completed the same day (LIHEAP not applicable).

 

View Medical Release Form  

 
Downloadable PDF's

Alabama High School Athletic Association - Sports Physical Form

Florida Sports Physical Form

FT Rucker Sports Physical Form

Georgia - Sports Physical Form

Medical Release Form