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REQUEST AN APPOINTMENT

New Patient Form

Patient Intake Form

Please fill out the form below and Click on Submit Form once completed.

Patient Information Form

Reason you require this Chiropody consultation :

First Name:

Last Name:

Middle Initial:

Birthdate (M/D/Y)

Age:

Gender:

Address:

City:

Postal Code:

Cell Number:

Landline:

Work Phone:

Preferred phone number to be reached?

Cell Phone

Landline

Work Phone

Email for correspondence with Simard Foot & Ankle Clinic

Emergency Contact Name (First and Last):

Emergency Contact Phone Number:

Relationship (Eg. mom, daughter):

Family Dr/NP's Name:

Family Dr/NP's Address (Location)

Employer:

Occupation:

Extended Health Benefits:

Yes

No

Primary Insurance Company (if Greenshield, also enter number):

Secondary Insurance Company:

Are you covered by any of the following?

Veteran’s Affair’s Canada

ODSP

Ontario Works

NIHB(First Nations/Inuit)

WSIB

How did you hear about us?

Internet

Social Media

Clinic Signage

Phone Book

Primary Physician/NP

Walk-in Clinic

ER Doctor

If you were referred to our our office, please enter individual's name:

PODIATRIC HISTORY: Please let us know more about your feet - When did your current issue start?

Location of your current issue (where on feet?):

What is the typical pain level of your current issue:

Have you had any major foot or leg injuries?

Yes

No

Have you ever had foot or ankle surgery?

Yes

No

If yes, by whom?

Date of surgery:

Have you ever received care from a foot health provider?

No, I have never received care for my feet

Yes, currently I see someone for my feet

Yes, but I am no longer seeing them

If yes, name of provider

Date of last visit:

Have you had previous Foot x-rays?

Yes

No

If yes, enter name of imaging facility:

Approximate date of Xrays:

Shoe Size:

What type of footwear do you most commonly wear?

MEDICAL HISTORY - Check all that apply

Heart

Heart Attack

Diabetes

Stroke

High Blood Pressure

Chest pain

Mitral Valve Prolapse

Muscle Disease

Skin Condition

Cancer History

Arrhythmia

Heart Murmur

I have none of the major diseases listed

RESPIRATORY ISSUES

Frequent Colds

Asthma

Bronchitis

None

ARTHRITIS

Osteoarthritis

Rheumatoid

Gout

None

GASTROINTESTINAL ISSUES

Acid Reflux

Bowel Disorders

Crohn's Disease

None

VASCULAR ISSUES

Anemia

Bleeding Disorders

Blood Clots

Sickle Cell

Swelling Phlebitis

Vein Problems

Poor Circulation

Leg Ulcerations

Spider Veins

Transfusions

Night Cramps

Varicose Veins

Leg Pain When Walking

None

PSYCHOLOGICAL

Psychiatric Condition

Alcohol Dependence

Depression

Drug Dependence

Other Illnesses not listed:

HAVE YOU EXPERIENCED ADVERSE SIDE EFFECTS FROM ANY OF THE FOLLOWING?

Aspirin/ASA

Neomycin/Polysporin

Steroids

Erythromycin

Novocain/Freezing

Sulfa Drugs

Latex

Penicillin

Tape allergy

Codeine

Iodine/Shellfish

Any other allergen that causes you adverse side effects?

Have you ever tested positive for Hepatitis or HIV?

Yes

No

Are you currently pregnant?

Yes

No

Height:

Weight:

Do you smoke tobacco?

Yes

No

Alcohol consumption:

None

1-2 week

1-2 day

more than 2 day

PLEASE LIST CURRENT MEDICATIONS: (If multiple medications please bring list from Pharmacy)

Which Pharmacy do you use?

Thank you for submitting your patient information form!

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Business Hours

Monday: 8:00 am - 4:30 pm
Tuesday: 8:00 am - 4:30 pm
Wednesday: 8:00 am - 4:30 pm
Thursday: 8:00 am - 4:30 pm
Friday: Closed
Saturday: Closed
Sunday: Closed

If preferred, our New Patient Form can also be downloaded and printed by clicking the button below.

DOWNLOAD NEW PATIENT FORM Call Us

Put your feet in good hands.

Get Directions Patient Intake Form (Printable)

QUICK LINKS

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NEW PATIENT INFO

CONTACT

(P) 705-759-8525
(F) 705-759-1749
reception@simardfootclinic.com
765 Queen St E #201,
Sault Ste. Marie, ON
P6A 2A8
Located in the Superior Health Centre
(old PUC building)

© 2025 Simard Foot & Ankle Clinic

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