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							<td align="center" style="background: #2e343e;"><img src="https://www.allistonphysiotherapy.com/cms/public/storage/setting/1742208443-logo.png" class="CToWUd" data-bit="iit" style="width: 250px;padding: 20px 0;">
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															<strong>PART A - Pertaining to Extended Health Care Centre</strong><br>
At Alliston Physiotherapy and Sports Rehabilitation, we are committed to providing a safe, respectful, and supportive environment<br> for both our clients and staff.
Abusive language, aggressive behavior, or any form of misconduct toward our staff will not be tolerated.<br>

We appreciate your cooperation in maintaining a positive and professional atmosphere for everyone.<br><br>

<strong>— Management Of Alliston Physiotherapy and Sports Rehabilitation</strong><br><br>
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															<td height="20" style="padding-left:10px" width="40%"><b>Patient Signature </b></td>
															<td width="5%">:</td>
															<td width="65%">{#sign}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Date Of Birth</b></td>
															<td width="5%">:</td>
															<td width="65%">{#date}</td>
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															<strong>OFFICE USE ONLY- INSURANCE INFORMATION</strong></td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Insurance Name </b></td>
															<td width="5%">:</td>
															<td width="65%">{#name}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Member Name</b></td>
															<td width="5%">:</td>
															<td width="65%">{#name}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Policy Number</b></td>
															<td width="5%">:</td>
															<td width="65%">{#policy}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>ID Number</b></td>
															<td width="5%">:</td>
															<td width="65%">{#no}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Total Max for Physio</b></td>
															<td width="5%">:</td>
															<td width="65%">{#total}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Percentage</b></td>
															<td width="5%">:</td>
															<td width="65%">{#percentage}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Total Of Message </b></td>
															<td width="5%">:</td>
															<td width="65%">{#total}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Percentage</b></td>
															<td width="5%">:</td>
															<td width="65%">{#percentage}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Total max Of Braces </b></td>
															<td width="5%">:</td>
															<td width="65%">{#total}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Percentage</b></td>
															<td width="5%">:</td>
															<td width="65%">{#percentage}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Policy year/Calendar yea</b></td>
															<td width="5%">:</td>
															<td width="65%">{#policy}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Update On</b></td>
															<td width="5%">:</td>
															<td width="65%">{#updated}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>By</b></td>
															<td width="5%">:</td>
															<td width="65%">{#by}</td>
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			<td>&nbsp;</td>
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						<td width="50%" style="color:#fff">Call Us: <a href="tel:7054340645" value="7054340645" target="_blank" style="color:#fff;">  705-434-0645</a><br>
						
						Email Id: <a href="mailto:info@allistonphysiotherapy.ca" style="color:#fff;"> info@allistonphysiotherapy.ca</a>
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						<td width="50%" style="text-align:right;color:#fff;">  Address: 27 Victoria Street E, Alliston, <br>ON L9R 1T9, Canada </td>
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