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Are you a new / established patient?*

New Patient

Established Patient

What is the age of the patient?*

0 to 7 years old

7 to 17 years old

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

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New Patient with 1 to 2 topics to discuss

New Patient with 3 to 4 topics to discuss

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

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.*

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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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