Welcome to AllStar Healthcare

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name="meta_web_form_id" value="841066435" /><!-- [et_pb_line_break_holder] --><input type="hidden" name="meta_split_id" value="" /><!-- [et_pb_line_break_holder] --><input type="hidden" name="listname" value="awlist4732370" /><!-- [et_pb_line_break_holder] --><input type="hidden" name="redirect" value="https://www.aweber.com/thankyou-coi.htm?m=text" id="redirect_cbd07b4a9f2dec4131335315b75fd755" /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="hidden" name="meta_adtracking" value="Patient_Information" /><!-- [et_pb_line_break_holder] --><input type="hidden" name="meta_message" value="1" /><!-- [et_pb_line_break_holder] --><input type="hidden" name="meta_required" value="name,custom Phone,email" /><!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --><input type="hidden" name="meta_tooltip" value="" /><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div id="af-form-841066435" class="af-form"><div id="af-header-841066435" class="af-header"><div class="bodyText"><p> </p></div></div><!-- [et_pb_line_break_holder] --><div id="af-body-841066435" class="af-body af-standards"><!-- [et_pb_line_break_holder] --><div class="af-element"><!-- [et_pb_line_break_holder] --><label class="previewLabel" for="awf_field-91666289">Name: </label><!-- [et_pb_line_break_holder] --><div class="af-textWrap"><!-- [et_pb_line_break_holder] --><input id="awf_field-91666289" type="text" name="name" class="text" value="" onfocus=" if (this.value == '') { this.value = ''; }" onblur="if (this.value == '') { this.value='';} " tabindex="500" /><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="af-clear"></div></div><!-- [et_pb_line_break_holder] --><div class="af-element"><!-- [et_pb_line_break_holder] --><label class="previewLabel" for="awf_field-91666290">Phone:</label><!-- [et_pb_line_break_holder] --><div class="af-textWrap"><input type="text" id="awf_field-91666290" class="text" name="custom Phone" value="" onfocus=" if (this.value == '') { this.value = ''; }" onblur="if (this.value == '') { this.value='';} " tabindex="501" /></div><!-- [et_pb_line_break_holder] --><div class="af-clear"></div></div><div class="af-element"><!-- [et_pb_line_break_holder] --><label class="previewLabel" for="awf_field-91666291">Email: </label><!-- [et_pb_line_break_holder] --><div class="af-textWrap"><input class="text" id="awf_field-91666291" type="text" name="email" value="" tabindex="502" onfocus=" if (this.value == '') { this.value = ''; }" onblur="if (this.value == '') { this.value='';} " /><!-- [et_pb_line_break_holder] --></div><div class="af-clear"></div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div class="af-element"><!-- [et_pb_line_break_holder] --><label class="previewLabel" for="awf_field-91666292">Insurance Type:</label><!-- [et_pb_line_break_holder] --><div class="af-textWrap"><input type="text" id="awf_field-91666292" 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