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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/Provider (please print) Specialty (if applicable) & Registration Number
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Address City, Province, Postal Code
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Phone Number Fax Number

SPART-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 functlonal 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 correspandence 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withdrawn In writing or | return to work successfully.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:

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