top of page

To book an appointment please contact us by phone at 905 239 9020

 

**Please note that new appointments or changes to existing appointments are not made via email. Please call the office directly. 

 

**Before your arrival at our office, please fill out the new patient intake form. This information is used to help design a custom treatment plan for you.  You can also fill out our new patient form once you have arrived in our office.


On behalf of the staff at the Harwood Foot Clinic, we look forward to meeting you soon!

OUR CLINIC LOCATION

Harwood Foot Clinic      

1 Rossland Road West Suite 202 (at the southwest corner of  Harwood Avenue and Rossland Road, second floor of the plaza)

Ajax, ON      

L1Z 1Z2

 

OUR CONTACT NUMBER

Phone: 905-239-9020

Fax:     905-239-9021

 

OUR CONTACT E-MAIL

Email: info@harwoodfootclinic.com

 

Harwood Foot Clinic

Wheelchair Accessible, Ample Free Parking

Hours

Monday : 9:00 AM - 5:00 PM

Tuesday : 9:00AM - 5:00 PM

Wednesday: 9:00AM - 4:30 PM
Thursday: 11:00 AM – 7:00 PM

Friday: 9:00 AM - 3:00 PM

Saturday: 9:00 AM – 3:00 PM (excluding July and August)

Sunday: Closed

Methods of Payment

New Patient Intake Form

Single choice
Miss
Ms
Mrs
Mr.
Dr.
Gender
Male
Female
Birth Date
Month
Day
Year
Medical Insurance (Extended Health Care?)
No
Yes
My Foot Problems Involve My:
Left Foot
Right Foot
Both Feet

MEDICAL INFORMATION

1. How is your general health?
Good
Fair
Poor
2. Are you subject to prolonged bleeding after tooth extractions or cuts?
Yes
No
3. Females – Are you Pregnant?
Yes
No

4. Have you ever been treated for any of the following?

COVID-19
Yes
No
Diabetes
Yes
No
Gout
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Polio
Yes
No
Difficulty in Healing
Yes
No
High Blood Pressure
Yes
No
Low Blood Pressure
Yes
No
Shortness of Breath
Yes
No
Any Heart Trouble
Yes
No
Phlebitis
Yes
No
Varicose Veins
Yes
No
Stomach Ulcer
Yes
No
Kidney Problems
Yes
No
Epilepsy
Yes
No
Liver Problems
Yes
No
5. Are you subject to nervous disorders, fainting or dizziness?
Yes
No
6. Are you taking any medicine at the present time?
Yes
No
7. Have you been to a foot specialist before?
Yes
No
8. Have you had any previous foot surgery?
Yes
No
9. Have you ever worn custom made orthotic devices?
Yes
No
10. Are you allergic to any of the following? (Check if YES)
11. Is there any other information about your health which we should know?
Yes
No

Who may we thank for referring you to this Office?

We appreciate your cooperation. THANK YOU.

patient intake form

Our Location

Hours: 

Monday : 9:00 AM - 5:00 PM

Tuesday : 9:00 AM - 5:00 PM

Wednesday: 9:00 AM - 4:30 PM
Thursday: 11:00 AM – 7:00 PM

Friday: 9:00 AM - 3:00 PM

Saturday: 9:00 AM – 3:00 PM (excluding July and August)

Sunday: Closed

General Information

Harwood Foot Clinic
1 Rossland Rd W Suite 202 Second Floor
Ajax, ON

L1Z 1Z2

Phone: 905-239-9020

Email: info@harwoodfootclinic.com

Service Area

Ajax/Pickering & GTA

Social

Copyright Harwood Foot Clinic

Created by
Yellow Pages for business
bottom of page