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															<td colspan="3" style="padding-left:10px;width:650px;">I hereby request and consent to the performance of physiotherapy treatments and other physiotherapy procedures and techniques,<br> including various modes of physical modalities, manual techniques and exercise on me by the physiotherapist. Physiotherapy<br> assistants/kinesiologist will be part of providing treatment and will work under physiotherapist supervision named below or<br> any provider covering for the treating physiotherapist working in this clinic authorized by the physiotherapist.<br>

I have had the opportunity to discuss with the physiotherapist<br> named below the nature and purpose of physiotherapy treatment and other procedures. I understand that results are not guaranteed <br>and only the treating physiotherapist will be responsible for any issues related or arising from treatment not the clinic, as all<br> health care practices, there are some slight risks of injury with treatment including, but not limited to, soft tissue<br> sprains/ strains, pain, heart attacks, stroke, etc. and agree to keep the therapist informed of any changes in my condition<br> (sometimes patients get bruising from soft tissue that’s normal). Also, I had the opportunity to discuss the<br> payment plan with the office administration regarding my private insurance, WSIB and MVA before IA.<br><br>

<strong>FEE STRUCTURE FOR WSIB AND MVA:</strong><br><br>


ALL WSIB AND MVA PAYMENTS WILL BE CHARGED AS PER THE STANDARD FEE GUIDE.FOR MVA WILL GO THROUGH YOUR EXTENDED<br> HEALTH INSURANCE FIRST.PER SESSION COST IS $99.75 AND INITIAL ASSESSMENT IS $215 FOR MVA.</td>
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															<strong>PRIVATE INSURANCE FEE STRUCTURE:</strong></td>
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															<td style="padding-left:10px" width="48%"> INITIAL ASSESMENT FOR ONE PART: $ 115<br>
    FOLLOWS UP SESSIONS: $75<br>
    INITIAL ASSESMENT FOR MULTI PARTS: $140<br>
    FOLLOWS UP SESSIONS: $100<br>
    INITIAL FOR TMJ: $130<br>
    FOLLOWS UP: $100<br>
    INITIAL FOR VESTIBULAR: $130</td>
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															<td width="48%">FOLLOWS UP: $100
    INITIAL FOR VESTIBULAR: $130<br>
    FOLLOW UP: $100<br>
    LASER THERAPY: $100 PER SESSION<br>
    SHOCKWAVE: $120 PER SESSION<br>
    ACCUPUNTURE $100 TRACTION: $100 PER SESSION<br>
    INITIAL ASSESSMENT CONCUSSION: $130<br>
    FOLLOWS UP SESSIONS: $100</td>
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															<td colspan="3" style="padding:10px 0 0 10px;width:650px;"><strong>CONSENT TO PAYMENT</strong><br><br>

I understand that I am responsible for payment of any fee for each treatment<br> unless this is paid for by my motor vehicle insurer or the Work Place Safety and Insurance Board.<br>
I understand that I am responsible for keeping scheduled appointments and that<br> I will be charged a full treatment charge for appointments missed including WSIB/MVA without prior cancellation by phone or in person.<br> All overdue and outstanding payments will be charged with an additional 5% interest after 30 days and any pending accounts<br> after 30 days will be transferred to our accounts department.</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Physiotherapist’s Name </b></td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Patient Name</b></td>
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															<td width="65%">{#sign}</td>
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															<td width="65%">{#sign}</td>
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															<td height="20" style="padding-left:10px" width="40%"><b>Date</b></td>
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															<td width="65%">{#date}</td>
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															<td colspan="3" style="padding:10px;width:650px;"><strong>ALL THE NO SHOW APPOINTMENTS WILL BE FULLY CHARGED.24 HOURS NOTICE IS REQUIRED PRIOR TO ANY RE SCHEDULE/CANCELLATION</strong></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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