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📁 MARK'S DOC
🔗 Linked Evidence
BCRTC_MEDICAL_QUESTIONARE — p.5
📄 BCRTC MEDICAL QUESTIONARE | p.5
📄 BCRTC MEDICAL QUESTIONARE | p.5
📝 Extracted Text (OCR)
bertc Other Comments or Recommended Graduated Return to Work Schedule: PHYSICIAN/HEALTH CARE PROVIDER INFORMATION: Please use Physician/Provider Stamp here or complete the below: Name of Attending Physician/Provider (please print) Specialty (if applicable) & Registration Number Address City, Province, Postal Code Phone Number Fax Number Physician/Provider Signature PART 3: EMPLOYEE CONSENT - MUST BE COMPLETED BY THE EMPLOYEE | authorize the healthcare professional who has signed this form to release to BCRTC Occupational Health and Wellness any functional abilities, limitations and/or restrictions information relevant to my current absence and return to work. | also authorize my healthcare professional to release, and discuss information concerning my Return to Work Plan. Furthermore, | consent to receiving correspondence related to my functional abilities, limitations and/or restrictions from Occupational Health & Wellness by email. | understand that a copy of this consent is as valid as the original. This consent is valid unless and until withdrawn in writing or | return to work successfully. Signature of Employee: Date: Page 5 of