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Agreement

I confirm that the information I have provided in regards to my current condition and past health history are to the best of my knowledge. I also acknowledge that it is my responsibility to update the clinic in regards to any changes in my health condition. I authorize my insurance benefits be paid directly to the clinic. I acknowledge that any treatment fees not covered by MVA will be my responsibility, and I understand that I am financially responsible for any balance. I authorize Active Rehab Centre or insurance company to release any information required to process my claims. I also authorize Active Rehab Centre to release information regarding my medical condition to my family physician.

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