The patient is responsible for any fees
canadasae ralated to the completion of this form.
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Attending Physician’s Statement - Sho

Pian Member/Employee Information and Consent: TO BE COMPLETED BY THE PATIENT

Plan Member/Employee Name (Last, First, Middle Initial) Home Phone # (+ Area Coda) Cell Phone # (+ Area Code)
Holand, Mark, T 236-994-3376

Address (Street, City, Province. Posta! Code)

311-318 Agnes St, New Westminster, BC, V3L 0J3

Employer's Name Group Plan Number Canada Life Employee Identification Number
BC Rapid Transit 50788 £21987

Last Date Worked Date Returned to Work or Expected Return to Work Date
(ddimmbyyyy) 29/01/2026 (adimmiyyyy)

| authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information and including
consultation reports, to Canada Lite for the purpose of investigating and assessing my claim(s), administering coverage(s) that | may have with Canada
Life and administering the group benefits pian. Medical and health information excludes genetic test results.

| acknowledge that the personal information is needed by Canada Life for the purposes stated above. | acknowledge that my consent enables
Canada Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).

This consent may be revoked by me at any time by sending a written instruction

| confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.
09/02/2026

Plan Member/Employee Signature Date of Consent (dd/mmiyyyy)

TO BE COMPLETED BY THE PHYSICIAN (or Nurse Practitioner Where Applicable)

* If your patient has returned to work or is expected to return to work within 4 weeks of the Last Date Worked, complete
Page 1 only and sign the end of the form.
* For absences expected to be greater than 4 weeks, please complete Pages 1 and 2 in full.

PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE

Primary Diagnosis: N Ri Sti FS

Secondary and/or Complications: rr ethe. UR SPEC 4)

If Childbirth - Expected or Actual Delivery Date (dd/mm/yyyy) Vaginal _! C-Section —)

Occupational Iliness/injury Yes 7 No |_ Auto Accident Yes) No!
It yes, date of event: (dd/mmyyyy) If yes, date of event: (dd/mmiyyyy)

Date of first visit to you pertaining to this condition: First date of work absence due to condition:

(Waimmyyyy) 3.9 fot [zor (ddimmiyyyy) 2b/ot/rorw b

Hospitalization Isiwas patient hospitalized __| or had day surgery |
Date of admittance (da/mmiyyyy): Date of discharge (dd/mmiyyyy) Institution Nama:

If surgery was performed please provide date and description of surgery

Date (dd/mmiyyyy): yy ! a Description:

Treatment (drug, dosage, physiotherapy, other):
weTec OnT

anadalite com + 1895: 755-6729

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