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Treatment Care Request
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Treatment Care Request
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Tell us, what's your Full Name?
First Name
Last Name
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What's your email address?
example@example.com
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3
What's your Mobile Number
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4
Address
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Street Address
Suite #
City
Province
Postal
Country
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5
Type of Recovery / Care
Motor Vehicle Accident
Personal Injury
Pre/Post Surgery
Other
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6
Do you have a claim #?
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NO
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7
Claim #
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8
Name of Auto Insurance?
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9
Date of Accident
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Date
Year
Month
Day
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10
Do you have extended health coverage?
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11
Extended Health Coverage Insurance
Manulife
Canada Life (Great West Life)
Sun Life Financial
SSQ Financial Group
Green Shield Canada
Medavie Blue Cross
Pacific Blue Cross
Industrial Alliance Insurance
La Capitale assurances et gestion du patrimoine
Empire Life Insurance Co
Equitable Life Insurance Co. of Canada
The Co-operators Life Insurance Co.
RBC Insurance
Assumption Life
GMS Insurance Inc
League
Johnson Inc.
Johnston Group Inc
Manulife Financial
Maximum Benefit
GroupSource
GroupHEALTH
CINUP
Chambers of Commerce Group Insurance
Cowan
Desjardins Insurance
First Canadian
Other / Not Shown
Manulife
Canada Life (Great West Life)
Sun Life Financial
SSQ Financial Group
Green Shield Canada
Medavie Blue Cross
Pacific Blue Cross
Industrial Alliance Insurance
La Capitale assurances et gestion du patrimoine
Empire Life Insurance Co
Equitable Life Insurance Co. of Canada
The Co-operators Life Insurance Co.
RBC Insurance
Assumption Life
GMS Insurance Inc
League
Johnson Inc.
Johnston Group Inc
Manulife Financial
Maximum Benefit
GroupSource
GroupHEALTH
CINUP
Chambers of Commerce Group Insurance
Cowan
Desjardins Insurance
First Canadian
Other / Not Shown
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12
Referring Provider or Referring Legal Team
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13
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