noe BONO

Continuation of Attending Physician’s Statement for Absences that may be Greater than 4 Weeks

Has the patient been treated for this same or similar condition in the past? Yes’ No

i yes, date (sammy: O2 Jt [Or lo _ Treatment Provider Self +r Lee! wilh Sma)

Please describe the patient's symptoms including history, severity and frequency:

Frequency of Visits: /\Neekly “| Monthly Other

Please attach copies of all relevant:

“Ly * test results/investigations (If test results are not attached, we will interpret this as tests were not performed)
* consultation reports

* do not provide genetic test results

lf consultation report is not attached, please indicate if the patient has or will be seen by a specialist for this condition.
Name of Specialist: Specialty: Date of Visit:

Based on your clinical findings and Dteee isons please describe the patient's current cognitive and/or physical functional abiliti

On

Please list any complications and additional conditions impacting your patient's level of function or the expacted recovery period.

Is the patient following the recommended treatment program?

Prognosis Please oy the prognosis for recovery: (if not completed on page 1)
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Notice to Physician

The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan administrator 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
Attending Physician (please print)

M GwGore Mery
Address (Street, City, Province, Postal Coda)

Sf
CA12 eos STL

Telephone # (+ Area Code) Fax # (+ Area Cade)

Got 321 Tol Got MN Prob

Email Address

Signature Date Signed (d/mmvyyyy)
= 19 fovcf2ork

anadalife.com + 1 855-755-6729

MSAS4{APS)-1/20

Certified Specialty
aa aloe ae 2914 RE

Dr. G. Ademiluy!
#68199
420 Columbia Street
New Westminster, BC, V3L 1B1
Ph 604-522-2206 Fax 604-522-7206