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canada fo opifiny’ REQUEST

Group Disability

Dr. G. Ademiluyi

Mark Holand

Reference ID : 130684485

Please note that genetic testing information is not required, so please do not
include. | acknowledge that the information in this statement will be kept ina
disability benefits file with Canada Life and might be accessible by the patient
or third parties to whom access has been granted or those authorized by law.
By providing the information | consent to such unedited release of any
information contained herein.

x

Signature Date

Full Name

Questions? Please call Opifiny™ Customer service: Generated by opifing | Request # QHBZWWZTH | May 14, 2026

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