Are you a new / established patient?* New Patient Established PatientSelect a Service Category* Pediatric AdultThis field is hidden when viewing the formSelect Age Options* Primary Care for Age 0 to 6 yearsSelect a Service* Baby's First Visit (required for up to 3 months of age) New Patient to establish care or with 1 topic to discuss New Patient with 2 to more topics to discussSelect a Service* New Patient's First Visit Covid-19 Prophylaxis Covid-19 Treatment, Virtual Visit Covid-19 Long Haul OR Post-Vaccine Long Haul DOT Physical Exam or USCG Physical Exam (This Visit Must Be In-Person) LDN MAT FOR OUD (for established patients only) TSM for AUD Work / School / Sports Physical (This Visit Must Be In-Person)Select a Service Category* Pediatric AdultThis field is hidden when viewing the formSelect Age Options* Primary Care for Age 0 to 6 yearsSelect a Service* 1 topic to discuss 2 or more topics to discussSelect a Service* Primary Care for 1 topic to discuss Primary Care for 2 or more topics to discuss Covid-19 Prophylaxis Covid-19 Treatment, Virtual Visit Covid-19 Long Haul OR Post-Vaccine Long Haul DOT Physical Exam or USCG Physical Exam 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.*
