Are you a new / established patient?* New Patient Established PatientWhat is the age of the patient?* 0 to 7 years old 7 to 17 years oldSelect 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 discussSelect a Service* New Patient with 1 to 2 topics to discuss New Patient with 3 to 4 topics to discussSelect a Service* 1 or 2 topics to discuss 3 or 4 topics to discussSelect a Service* 1 or 2 topics to discuss 3 or 4 topics to discussI 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.*NameThis field is for validation purposes and should be left unchanged.
