FOREMED_FAX_MARCH_24-26_6-6 — p.1
📄 FOREMED FAX MARCH 24-26 6-6 | p.1
📄 FOREMED FAX MARCH 24-26 6-6 | p.1
📝 Extracted Text (OCR)
‘A nariae 2:02:*3 PM ‘Translink 658-1212 68 Be, PHYSICIAN/HEALTH CARE PROVIDER INFORMATION: Please use Physician/Provider Stamp here or complete the below: ney AEN oR CeocRoraée (bewistt Fever Tame of Ate Phys raae oleate wit) Speci fappleable)& hepsvaton Number 429 COlLnmBiA Sire eb BO, nity deste se Taras Thy, Province, PostalCode VSL E 7 Gor Qa web Gor SRP b Prone Number Fax flumbar a Dr. G. Ademiluyi 68199 Tina Tgatore TAT 5 EMPLOVEE CONSE “AUST BE COMPLEVED THE UALOVEE a] |sutharite the healthcare professional who has signed this form te release to BCRYC Occupational Health and Wellness any functional abilities imitations and/or restrictions information relevant to my current |, sence ane rerun to work alo authori my healthcare profesional ta release, and discuss information concerning my Retura te Work Plan Furthermore consest to receiving correspondance related to my | tutional abilities, imitations and/or cestietions from Occupational Health & Wellness by ema. | unowstand thot conyf ths consent a8 val asthe gral. This consents valid unas and unt | || itherawn in wrltng or return to werk sucessfully | stnatuce of employees ate