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Receipt For Health Care
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Health Issue: Complains of __
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NATUROPATHIC / NATUROTHERAPEUTIC CARE
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VISIT #1
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Date:
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Location of Care
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Amount: $____
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VISIT #2
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Date:
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Location of Care
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Amount: $____
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VISIT #3
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Date:
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Location of Care
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Amount: $____
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VISIT #4
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Date:
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Location of Care
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Amount: $____
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VISIT #5
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Date:
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Location of Care
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Amount: $____
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VISIT #6
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Date:
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Location of Care
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Amount: $____
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VISIT #7
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Date:
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Location of Care
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Amount: $____
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VISIT #8
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Date:
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Location of Care
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Amount: $____
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VISIT #9
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Date:
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Location of Care
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Amount: $____
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VISIT #10
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Date:
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Location of Care
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Amount: $____
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Payment Method
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TOTAL Amount (including taxes)
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TOTAL amount, in printed letters
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TOTAL number of visits, in printed letters:
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Federal Registration No. (81284 0130 RT0001)
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Provincial Registration No (PST#)
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Naturopath's (N.D.) / Naturotherapist's (n.d.) Identification and Declaration
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Receipt Number:
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Date: YYYY-MM-DD
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Signature
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