Health Questionnaire

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PLEASE TAKE YOUR TIME and DON'T RUSH! When you hit the SUBMIT button your form goes directly to our doctors.

Your detailed answers help OUR TEAM to determine appointment timing, effectiveness and increase the efficiency once you come to health:latch. Your appointment starts now!

Baby's Name *

First and Last Name

Baby's Date of Birth *

YYYY

Baby's Gender *

Female

Male

Name Parent 1 *

First and Last Name

Parent 1 Date of Birth *

YYYY

Parent 1 Relationship to Baby *

Mother

Father

Name Parent 2

First and Last Name

Parent 2 Date of Birth

YYYY

Parent 2 Relationship to Baby

Mother

Father

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Home (FULL) Address *

Important: Please include COMPLETE mailing address - street address, city and zip code

Best Email Address *

Best Phone Number *

(XXX) XXX-XXXX

May we text this phone number? *

We have found that texting is the easiest and most efficient form of communication.

Yes

Would you like medical and dental codes emailed to you? *

While we do not accept insurance, we do our best to provide you with the right information to seek reimbursement from your insurance carrier. Prior to your appointment, we can email you a list of medical and dental codes so that you can research your coverage.

Yes

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