Name* First Last Are you still in active treatment?*YesNoIf so, what treatment? Physiotherapy Chiropractic Massage TMJ / Dental Acupuncture Other Has your AB (Auto) Insurer given an extension on the number of treatments for direct billing?*YesNoUnsureHas any treatment been recommended, but hasn't occurred? Can you provide detailsWhat injury symptoms do you currently have?*Who is paying for treatment now?* AB Insurer (Your Auto Insurer) Extended Health Care Benefits Alberta Health Care Myself Unsure Unreimbursed Treatment ReceiptsDo you have any questions or concerns that I can assist with?NameThis field is for validation purposes and should be left unchanged.