New Patient Forms

New patients are always welcome at OttawaFootPractice. We are committed to providing the best quality of care and understanding to those who bring their foot and ankle problems to us. Please feel free to learn more about our practice and our services if you have not already.

A first-time visit to any office can be slightly stressful. We try to provide an easier experience by offering our New Patient Form to you in advance. This form can be downloaded, printed out, and completed at home. Bring it with you to your appointment and it can save you time in the waiting room. We can then get to the important part of addressing your needs all that much faster!

If you have further questions about OttawaFootPractice or what you can expect during your first visit with us, please call us at (613) 595-9700.

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OttawaFootPatient













Parent name (if under 18 year-old), guardian name or primary care name and phone number


Emergency Contact Name and phone number



If you would like your family doctor to receive a report of your consultation this information must be completely correctly.









Percentage of time at work




Percentage of time at home









YesNo

YesNo
I wear my current orthotics


Health Summary


YesNo

YesNo

YesNo

YesNo


ExcellentGoodAveragePoor

YesNoThere may be a possibility

AnemiaAsthmaAdhesive TapePoor CirculationRheumatic FeverShortness of BreathErythromycinGoutTylenolDiabetesDifficulty HealingLiver ProblemPhlebitisAspirin (ASA)CodeineHeart ProblemsHigh Blood PressureUlcersCancerNovocainCortisoneKidney ProblemsPenicillinSulphaEpilepsyHepatitis


YesNo

YesNo

YesNo

YesNo


YesNo


I hereby give my permission to Pierre Dupont, Doctor of Podiatry Medicine / Registered Chiropodist to examine and treat my feet medically, surgically or orthopedically. I acknowledge that fees for services are not covered by OHIP and are payable each treatment session. I also acknowledge the required reschedule or cancellation policy of two business day notice to avoid an office charge. Missed appointments will also be charged in full for the scheduled service reserved.

Find Relief For Many Foot And Ankle Conditions With OttawaFootPractice!