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 $25 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).

Downloadable PDF’s