Print Envelope Share-alt Schedule your visit Book an appointment 012 98 10 16 Filll in the form Who do you make appointment for? Please select For myself For my daugther For my son For my husband For my wife For my brother For my sister For my relative For my friend What's the reason for your visit? Please select Speech Problem Autism ADHD Learning difficulty Behavior problems Convulsion/fit Epilepsy Headaches Abnormal facial twitches Abnormal movements Fear Depression Bizarre behavior Has the patient visited this clinic before? Please select No Yes Select date Select time Please select 9:00 am 10:00 am 11:00 am 12:00 pm 1:00 pm 2:00 pm 3:00 pm 4:00 pm 5:00 pm First name Last name Date of birth Sex assigned at birth Please select Male Female Phone number Email Message I accept the Terms of Service Book an appointment >