[et_pb_section fb_built=”1″ disabled_on=”off|off|off” _builder_version=”4.19.0″ _module_preset=”default” background_enable_color=”off” background_image=”https:\/\/www.latitudeclinic.com\/wp-content\/uploads\/Paper-texture-background.png” global_colors_info=”{}”][et_pb_row _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.0″ _module_preset=”default” header_text_align=”center” global_colors_info=”{}”]<\/p>\n
[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=”1″ custom_padding_last_edited=”on|phone” _builder_version=”4.18.0″ _module_preset=”default” background_color=”#00AEEF” background_enable_image=”off” custom_padding=”100px||100px||true|false” custom_padding_tablet=”||80px||false|false” custom_padding_phone=”||80px||false|false” global_colors_info=”{}”][et_pb_row use_custom_gutter=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.19.0″ _module_preset=”default” background_color=”#FFFFFF” custom_padding=”40px|40px|40px|40px|true|true” custom_padding_tablet=”30px|30px|30px|30px|true|true” custom_padding_phone=”20px|20px|20px|20px|true|true” border_radii=”on|10px|10px|10px|10px” box_shadow_style=”preset1″ box_shadow_blur=”8px” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.0″ _module_preset=”default” text_font=”|300|||||||” text_text_color=”#343434″ custom_padding=”||0px|||” global_colors_info=”{}”]<\/p>\n
Links to complete the NEW PATIENT FORMS ONLINE (preferred method)<\/strong><\/p>\n Pediatric New Patient Forms (age 0 to 17)<\/a><\/strong> [\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.19.0″ _module_preset=”default” background_color=”#FFFFFF” custom_padding=”40px|40px|40px|40px|true|true” custom_padding_tablet=”30px|30px|30px|30px|true|true” custom_padding_phone=”20px|20px|20px|20px|true|true” border_radii=”on|10px|10px|10px|10px” box_shadow_style=”preset1″ box_shadow_blur=”8px” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.0″ _module_preset=”default” text_font=”|300|||||||” text_text_color=”#343434″ width=”100%” global_colors_info=”{}”]<\/p>\n PDF of New Patient Forms to print and complete, scan and email to ringling@latitudeclinic.com<\/a> or bring to your first visit.<\/strong><\/p>\n Pediatric New Patient Forms (age 0 to 17)<\/a> [\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.19.0″ _module_preset=”default” background_color=”#FFFFFF” custom_padding=”40px|40px|40px|40px|true|true” custom_padding_tablet=”30px|30px|30px|30px|true|true” custom_padding_phone=”20px|20px|20px|20px|true|true” border_radii=”on|10px|10px|10px|10px” box_shadow_style=”preset1″ box_shadow_blur=”8px” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.0″ _module_preset=”default” text_font=”|300|||||||” text_text_color=”#343434″ width=”100%” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″]<\/p>\n If you need Latitude Clinic to request or send records, use this form.\u00a0<\/strong><\/p>\n Consent for Latitude Clinic to REQUEST records\u00a0ONLINE FORM<\/strong><\/a><\/p>\n Consent for Latitude Clinic to RELEASE records\u00a0ONLINE FORM<\/strong><\/a><\/p>\n Consent for Latitude Clinic to REQUEST records PDF to print, complete and email to ringling@latitudeclinic.com or bring to visit<\/a> [\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.19.0″ _module_preset=”default” global_colors_info=”{}”][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=”on” custom_padding_last_edited=”on|phone” _builder_version=”4.19.0″ _module_preset=”default” background_color=”#FFFFFF” custom_padding=”40px|127px|40px|127px|true|true” custom_padding_tablet=”30px|30px|30px|30px|true|true” custom_padding_phone=”20px|20px|20px|20px|true|true” border_radii=”on|10px|10px|10px|10px” box_shadow_style=”preset1″ box_shadow_blur=”8px” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.19.0″ _module_preset=”default” text_font=”|300|||||||” text_text_color=”#343434″ width=”100%” global_colors_info=”{}”]<\/p>\n Pediatric SCREENING Questionnaires <\/strong><\/p>\n (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)<\/p>\n 2 Month Questionnaire ASQ \u00a0(1 month 0 days through 2 months 30 days)<\/a><\/p>\n 4 Month Questionnaire ASQ \u00a0(3 months 0 days through 4 months 30 days<\/span>)<\/a><\/p>\n 6 Month\u00a0Questionnaire ASQ \u00a0(5 months 0 days through 6 months 30 days)<\/span><\/a><\/p>\n 8 Month Questionnaire ASQ \u00a0(7 months 0 days through 8 months 30 days)<\/span><\/a><\/span><\/p>\n 10 Month Questionnaire ASQ \u00a0(9 months 0 days through 10 months 30 days)<\/span><\/a><\/span><\/p>\n 12 Month \/ 1 Year Questionnaire ASQ \u00a0(11 months 0 days through 12 months 30 days)<\/span><\/a><\/span><\/p>\n 14 Month Questionnaire ASQ \u00a0(13 months 0 days through 14 months 30 days)<\/span><\/a><\/span><\/p>\n 16 Month Questionnaire ASQ \u00a0(15 months 0 days through 16 months 30 days)<\/span><\/a><\/span><\/p>\n 18 Month \/ 1.5 Year Questionnaire ASQ \u00a0(17 months 0 days through 18 months 30 days)<\/span><\/a><\/span><\/p>\n 18 Month \/ 1.5 Year \u00a0M-CHAT: Autism Screening<\/a><\/span><\/p>\n 20 Month Questionnaire ASQ \u00a0(19 months 0 days through 20 months 30 days)<\/span><\/a><\/span><\/p>\n 22 Month Questionnaire ASQ \u00a0(21 months 0 days through 22 months 30 days)<\/span><\/a><\/span><\/p>\n 24 Month \/ 2 Year Questionnaire ASQ \u00a0(23 months 0 days through 25 months 15 days)<\/span><\/a><\/span><\/p>\n 24 Month \/ 2 Year M-CHAT: Autism Screening<\/a><\/span><\/p>\n 27 Month Questionnaire ASQ \u00a0(25 months 16 days through 28 months 15 days)<\/span><\/a><\/span><\/p>\n 30 Month \/ 2.5 Year Questionnaire ASQ \u00a0(28 months 16 days through 31 months 15 days)<\/span><\/a><\/span><\/p>\n 36 Month \/ 3 Year Questionnaire ASQ \u00a0(34 months 16 days through 38 months 30 days)<\/span><\/a><\/span><\/p>\n
Adult New Patient Forms (age 18 and up)<\/a><\/strong><\/p>\n
Adult New Patient Forms (age 18 and up)<\/a><\/p>\n
Consent for Latitude Clinic to RELEASE records\u00a0<\/a>PDF to print, complete and email to ringling@latitudeclinic.com or bring to visit<\/a><\/a><\/a><\/p>\n