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PHYSICIAN/HEALTH CARE PROVIDER INFORMATION:
Please use Physician/Provider Stamp here or complete the below:

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Name of Attending Physiclan/Pravider (please print) Specialty (Ifapplicable) & Registration Number
Qo CoLAmBA SreeeT_ BCE , tu WesTe Im sTAC
Address Clty, Province, PostalCode VW BC-( & /

bot 22 2ob Got SX P26
Phone Number Fax Number
a Dr. G, Ademiluyi
Physician/Provider Signature # 68199

420 Columbia Street,

New Westminste:
604-522-2206 Fax:604-522-7206

“MUST BE.COMPLETED'BY.THE EMPLOYEE

“PARTS:

|authorlze the healthcare professional who has signed this farm 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 ta release, and discuss informatian
concerning my Return to Work Plan, Furthermore, | consent to receiving correspondence related to my
functional abilities, limitations and/or restrictions fram Occupational Health & Wellness by email. |
understand that a copy of this consent is as valld as the original. This consent is valid unless and until
withdrawn in welting or | return to work successfully,

Signature of Employee: —

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