@extends('themes.frontend.layouts.app')
@section('flatpickr') @stop
@section('validate') @stop

@if (isset($dataArr['meta_title']))
@section('page-title'){{ $dataArr['meta_title'] }}@stop
@else
@section('page-title'){{ $dataArr['title'] }}@stop
@endif
@if (isset($dataArr['meta_key']))
@section('meta-keywords'){{ $dataArr['meta_key'] }}@stop
@endif
@if (isset($dataArr['meta_descp']))
@section('meta-description'){{ $dataArr['meta_descp'] }}@stop
@endif
@if (isset($dataArr['image_path']))
@section('meta-image'){{ $dataArr['image_path'] }}@stop
@endif
@if ($dataArr['full_url'])
@section('cur-url'){{ $dataArr['full_url'] }}@stop
@endif

@push('styles')
@if(isset($dataArr['custom_fields']['textarea_4']) && $dataArr['custom_fields']['textarea_4'] && $dataArr['custom_fields']['textarea_4']['value'])
<!--====== START: CUSTOM PAGE CSS from backed the Page ======-->
<style scoped>
		{!! $dataArr['custom_fields']['textarea_4']['value'] !!}
</style>
<!--====== END: CUSTOM PAGE CSS from backed the Page ======-->
@endif
@endpush

@section('content')
<!--====== BANNER PART START ======-->
@include('themes.frontend.includes.breadcrumb',['titleClass'=>'text-white'])
<!--====== BANNER PART ENDS ======-->

<!--==================================================-->
<!-----Start contact Section Style Seven ----->
<!--===================================================-->
@if (isset($dataArr['custom_fields']['editor_1']))
    {!!  app(App\Services\ShortcodeProcessor::class)->process($dataArr['custom_fields']['editor_1']['value']) !!}
@endif
<section class="appoinment-form  appointment-page pt-pb-130 ">
    <div class="container">
      <div class="row">
        <div class="col-xl-12">
          <div class="appoinment-box">
                <center>
                  <h1>ALLISTON PHYSIOTHERAPY &amp; SPORTS REHABILITATION</h1>
                  <h4>Respectful Conduct Policy</h4>
                </center>
                <div class="row">

    <form action="#" name="new_patient" id="new_patient" method="post" novalidate="novalidate">
                <div class="pq-appointment">

           <div class="row">
             
                <div class="col-lg-12">
	<h6 class="text-white">PART A - Pertaining to Extended Health Care Centre</h6>
<p>At Alliston Physiotherapy and Sports Rehabilitation, we are committed to providing a safe, respectful, and supportive environment for both our clients and staff.<br>
<strong>Abusive language, aggressive behavior, or any form of misconduct toward our staff will not be tolerated.</strong><br>
We appreciate your cooperation in maintaining a positive and professional atmosphere for everyone.<br>
— Management Of Alliston Physiotherapy and Sports Rehabilitation</p>
		</div>
                <div class="col-lg-6  ">
						Patient Signature 
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-name-field" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 

                <div class="col-lg-6  ">
						Date 
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="date"   placeholder=""   autocomplete="off">
		</div>
                <div class="col-lg-12">
	<h6 class="text-white">OFFICE USE ONLY- INSURANCE INFORMATION</h6>
		</div>
               <div class="col-lg-6  ">
						Insurance Name
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-name-field" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 

                 <div class="col-lg-6  ">
						Member Name
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-name-field" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
                <div class="col-lg-6  ">
						Policy Number 
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div>
			   <div class="col-lg-6  ">
						ID Number 
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			   
			  <div class="col-lg-6  ">
						Total Max for Physio
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder="$"   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						Percentage
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						Total for Massage
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder="$"   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
					 Percentage
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						Total Max for Braces
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder="$"   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						Percentage
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			    <div class="col-lg-12 ">
						Policy year/Calendar year
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						Update On
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
			    <div class="col-lg-6  ">
						By
				<span class="required text-danger">*</span>		
	<input class="form-control pq-bg-white paitent-dob-field date_empty" id="" name="" required="required" type="text"   placeholder=""   autocomplete="off">
		</div> 
               
            </div>

                
            
            <div class="col-lg-12  ">
		
	<center>
                    <div class="quote_btn pb-4 ">
                        <div class="pq-button-block">
                            <button type="button" class="pq-button-text me-0" id="send_new_patient" name="send_new_patient">Submit Now</button>                        </div>
                    </div>
                </center>
		</div>        </div>
    </form>

    
        
    <!-- END: FORM -->

    

</div>



          </div>
        </div>

      </div>
    </div>
  </section>

@stop