PART A - Pertaining to Extended Health Care Centre
At Alliston Physiotherapy and Sports Rehabilitation, we are committed to providing a safe, respectful, and supportive environment for both our clients and staff. Abusive language, aggressive behavior, or any form of misconduct toward our staff will not be tolerated.
We appreciate your cooperation in maintaining a positive and professional atmosphere for everyone.
— Management Of Alliston Physiotherapy and Sports Rehabilitation
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| Patient Signature |
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| Date Of Birth |
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OFFICE USE ONLY- INSURANCE INFORMATION
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| Insurance Name |
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| Member Name |
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| Policy Number |
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| ID Number |
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| Total Max for Physio |
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| Percentage |
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| Total Of Message |
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| Total max Of Braces |
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| Percentage |
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| Policy year/Calendar yea |
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Thank you for contacting us. We have received your Form
Submission our Staff will be contacting you within 24 hours.
Have a great day ahead!
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