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Are you a new / established patient?*

New Patient

Established Patient

Select a Service Category*

Pediatric

Adult

Select Age Options*

Primary Care for Age 0 to 6 years

Primary Care for Age 7 years to 17 years

Select a Service*

Baby's First Visit (required for up to 3 months of age)

New Patient with 1 to 2 topics to discuss

New Patient with 3 to 4 topics to discuss

Select a Service*

New Patient with 1 to 2 topics to discuss

New Patient with 3 to 4 topics to discuss

Select a Service*

New Patient's First Visit

Covid-19 Prophylaxis

Covid-19 Treatment, Virtual Visit

Covid-19 Long Haul OR Post-Vaccine Long Haul

FMACSA Certified DOT Physical Exams (This Visit Must Be In-Person)

LDN

MAT FOR OUD

TSM for AUD

Work / School / Sports Physical (This Visit Must Be In-Person)

Select a Service Category*

Pediatric

Adult

Select Age Options*

Primary Care for Age 0 to 6 years

Primary Care for Age 7 years to 17 years

Select a Service*

1 or 2 topics to discuss

3 or 4 topics to discuss

Select a Service*

1 or 2 topics to discuss

3 or 4 topics to discuss

Select a Service*

Primary Care for 1 or 2 topics to discuss

Primary Care for 3 or 4 topics to discuss

Covid-19 Prophylaxis

Covid-19 Treatment, Virtual Visit

Covid-19 Long Haul OR Post-Vaccine Long Haul

FMACSA Certified DOT Physical Exams (This Visit Must Be In-Person)

LDN

MAT FOR OUD

TSM for AUD

Work / School / Sports Physical (This Visit Must Be In-Person)

I agree to the following:

I agree to arrive 20 min prior to my appointment to complete the required paperwork, I understand that being late will result in the appointment being rescheduled and the No Show Fee being applied.*

I agree to arrive 20 min prior to my appointment to complete the required paperwork, I understand that being late will result in the appointment being rescheduled and the No Show Fee being applied.*

I will arrive ready to give a urine sample, this is not a drug test but is required as part of the DOT Exam.*

I will arrive ready to give a urine sample, this is not a drug test but is required as part of the DOT Exam.*

If I have any medical conditions, I will review This Information and bring any required documentation with me, failure to bring all required documentation will result in a second scheduled visit and a repeat visit fee of $85 to complete the exam and paperwork.*

If I have any medical conditions, I will review This Information and bring any required documentation with me, failure to bring all required documentation will result in a second scheduled visit and a repeat visit fee of $85 to complete the exam and paperwork.*

I agree to Latitude Clinic’s Terms, Conditions and Consents.*

I agree to Latitude Clinic's Terms, Conditions and Consents.*

I agree to complete the New Patient Forms prior to the appointment. I understand that failure to complete the New Patient Forms will result in me being charged the No Show Fee and needing to reschedule my appointment.*

I agree to complete the New Patient Forms prior to the appointment. I understand that failure to complete the New Patient Forms will result in me being charged the No Show Fee and needing to reschedule my appointment.*

I agree to arrive at least 10 min prior to my appointment time, I understand that being late will result in the appointment being rescheduled and the No Show Fee being applied.*

I agree to arrive at least 10 min prior to my appointment time, I understand that being late will result in the appointment being rescheduled and the No Show Fee being applied.*

I agree to Latitude Clinic’s Terms, Conditions and Consents.*

I agree to Latitude Clinic's Terms, Conditions and Consents.*

I agree to Latitude Clinic’s Terms, Conditions and Consents.*

I agree to Latitude Clinic's Terms, Conditions and Consents.*

Disclosure

Vanessa Hamalian

is a Family Practice Registered Nurse, Florida Autonomous Practice License
APRN9272277

Sonya Meritt

is a Family Practice Registered Nurse, Florida Autonomous Practice License
APRN3171322

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NOTICE: The elevator in our building in Sarasota will be renovated soon. The projected start date is 5-29-2023. The elevator will be inoperable for about 4 weeks. Please give us a call if you need assistance on the stairs or if you cannot use the stairs and we will accommodate you as best we can.

Scheduling Notification!

Already fill up the History & Consent Form?

If not, please fill up History & Consent Form first before scheduling when first time to visit. Thank you!

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