Links to complete the NEW PATIENT FORMS ONLINE (preferred method)

Pediatric New Patient Forms (age 0 to 17)
Adult New Patient Forms (age 18 and up)

PDF of New Patient Forms to print and complete, scan and email to ringling@latitudeclinic.com or bring to your first visit.

Pediatric New Patient Forms (age 0 to 17)
Adult New Patient Forms (age 18 and up)

If you need Latitude Clinic to request or send records, use this form. 

Consent for Latitude Clinic to REQUEST records ONLINE FORM

Consent for Latitude Clinic to RELEASE records ONLINE FORM

Consent for Latitude Clinic to REQUEST records PDF to print, complete and email to ringling@latitudeclinic.com or bring to visit
Consent for Latitude Clinic to RELEASE records PDF to print, complete and email to ringling@latitudeclinic.com or bring to visit

Pediatric SCREENING Questionnaires

(Print and complete at home several days before the appointment and bring to the next Well Child Visit, or we are happy to print a copy to take home with you to complete prior to your next visit)

2 Month Questionnaire ASQ  (1 month 0 days through 2 months 30 days)

4 Month Questionnaire ASQ  (3 months 0 days through 4 months 30 days)

6 Month Questionnaire ASQ  (5 months 0 days through 6 months 30 days)

8 Month Questionnaire ASQ  (7 months 0 days through 8 months 30 days)

10 Month Questionnaire ASQ  (9 months 0 days through 10 months 30 days)

12 Month / 1 Year Questionnaire ASQ  (11 months 0 days through 12 months 30 days)

14 Month Questionnaire ASQ  (13 months 0 days through 14 months 30 days)

16 Month Questionnaire ASQ  (15 months 0 days through 16 months 30 days)

18 Month / 1.5 Year Questionnaire ASQ  (17 months 0 days through 18 months 30 days)

18 Month / 1.5 Year  M-CHAT: Autism Screening

20 Month Questionnaire ASQ  (19 months 0 days through 20 months 30 days)

22 Month Questionnaire ASQ  (21 months 0 days through 22 months 30 days)

24 Month / 2 Year Questionnaire ASQ  (23 months 0 days through 25 months 15 days)

24 Month / 2 Year M-CHAT: Autism Screening

27 Month Questionnaire ASQ  (25 months 16 days through 28 months 15 days)

30 Month / 2.5 Year Questionnaire ASQ  (28 months 16 days through 31 months 15 days)

36 Month / 3 Year Questionnaire ASQ  (34 months 16 days through 38 months 30 days)

42 Month Questionnaire ASQ  (39 months 0 days through 44 months 30 days)

48 Month / 4 Year Questionnaire ASQ (45 months 0 days through 50 months 30 days)