FORMS

Download the Forms You Need at Your Convenience

REFERRAL

Visits with our physicians are covered by OHIP if you are referred to them by your family physician, a nurse practitioner, or a specialist. Please print this form, present it to your physician or nurse practitioner, and have them fax it to our clinic at 613-701-1223. We’ll contact you to schedule an appointment once we receive and review your referral.

This form takes 3-5 minutes to complete.

NEW PATIENT INTAKE

In order to accept you as a patient, we need to know who you are, how we can reach you, and who we should contact in the event of an emergency.  We also need to familiarize you with some important clinic policies and obtain your consent to treat and communicate with you.

This form takes 5-10 minutes to complete.

PATIENT HISTORY

In order to provide the best care possible, our physicians need to know your medical history.  Please complete this form and bring it with you to your first appointment.  This will save you time and make your first visit more productive.  For privacy reasons, please do not record your name on the form.

This form takes 20-30 minutes to complete.

THREE-DAY FOOD RECORD

Understanding your meal and snack habits is key to developing a nutrition plan. Keeping a record of what you eat and drink for at least three days helps you and your healthcare team identify your nutrition strengths and where there are opportunities for improvement. Record what you eat and drink as it happens.  Be honest and, where possible, include amounts.  The days you record do not have to be consecutive.  Bring your record to your appointment with your registered dietitian.

This form takes 5-10 minutes to complete.

FOOD PREFERENCES

This form to tell us what you foods you like and what you dislike. Your meal plan will better match your preferences and be more useful to you if we know more about your tastes.  Bring this form to your registered dietitian who will use this information to develop your multi-day meal plan.

This form takes 5-10 minutes to complete.

NOTE: Only complete this form if you have purchased the meal-planning service.

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