QPILogoPNG W2

Call 514-747-3668

QPILogoPNG W2

  • open on saturdays

  • We accept emergencies

  • No medical reference needed

  • Covered by most private insurance plans

  • Preventive and surgical foot care

  • Treating feet of all ages

  • Save time and fill out paperwork safely and securely online

  • Treating sports injuries, fractures and heel pain

Patients | Quebec Podiatric Institute

Online New Patient Form

Please complete the Online New Patient Form and click the "Send" button.

Fields marked with * are required.

Online New Patient Form

First name is required

Last name is required.

Sex is required.

Month is required

Day is required.

Year is required.

Address is required.

Your city is required.

Your State is required.

Home phone is not valid.

Cell phone is not valid.

Your email is not valid.

Invalid Input

Invalid Input

Invalid Input

Relationship of Emergency Contact is required.

Health Insurance Card required

Field is required.

Field is required.

Field is required.

Field is required.


In your employment do you:
Field is required.

Field is required.

Field is required.

Field is required.

Field is required.

Field is required.

Field is required.

Field is not valid.

Field is not valid.


Please list any medication you take, prescription and over the counter:

Name of Medication      Reason for taking it      How often do you take it
Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Your height is required.

Your weight is required.

Your right shoe size is required.

Your left shoe size is required.

Yes or No is required.

Quantity is required.

Yes or No is required.

Yes or No is required.

Field is required.


Patient Financial Policy
PATIENT FINANCIAL POLICY
I understand that all podiatry fees are not covered by the RAMQ.

Patients who carry health insurance should remember that professional services are rendered and charged to the patient and not the insurance companies. Your insurance is a personal contract between you and your insurance company.

Payment is due in full on the date of service, unless other arrangements have been made or we have a contract stating otherwise.

The consultation fees for a new patient is 105$ ( no taxable). We accept cash, check, Visa, Master Card, Discover, Diner’s Club and American Express.

Past due accounts are subject to collection proceedings. All fees including, but not limited to collection fees, attorney and court fees shall become your responsibility in addition to the balance due this office.
There is a service fee of $25.00 for all returned checks.

There is a service fee of $45.00 for missed appointments. 24 hour notification is required for cancellations.

There are certain surgical procedures that require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due the day of the surgery.

I hereby authorize payment directly to Quebec Podiatric Institute for the surgical and or medical benefits, if any, otherwise payable to me for services. I understand that I am financially responsible for the charges not covered by my insurance.

I authorize Quebec Podiatric Institute to release any information, for insurance purposes, required in the course of my treatment.


Patient Record Of Disclosures

You may leave messages with, discuss my treatment, appointment or other scheduling that may occur or give other information as necessary with the following family, friends or personal representatives. I understand that Quebec Podiatric Institute will refuse to discuss my information with anyone NOT listed below, except in a life-threatening emergency. I also understand that this consent does not apply to medical providers.

Please print names and phone (Family, friends or personal representatives):
Field is required.

Yes is required.

I agree is required.

Your First Name and Last Name are required.

Date is required.