For more than 25 years at your service!

First visit

Medical Questionnaire

New patients

For your first visit, it’s important that you fill in a form providing us with all the information about your health. To speed up the process, we invite you to complete the form before your appointment.

Patient Name
Address
Date of Birth
Exp RAMQ

Medical information

Present health problems
Tick, if applicable.
Declaration of consent
Clear Signature
If you are unable to keep your appointment, you must notify us at least 48 hours in advance, otherwise you will have to pay a fee of $60.
PODIATRIC CARE IS NOT COVERED BY THE RÉGIE DE L'ASSURANCE-MALADIE DU QUÉBEC
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