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Mar 26, 2026 01:45 To: +16045205552 Page 05/10 From: Foremed Medica! Clinic Fax: 16043985612

2628/Mar/(24 2:02:43 PM Transilink 555;

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

eave ia rrEnicrm E&
™ (Re 6Roraé Ab Beier | FA er

Name of Attending Physiclan/Provider (please print} Specialty (Ifappltcable) & Registration Number ,

At? COL4MG, Spe G6 oo SC. PNY RYESTRO 1 gTRh

“address Clty, Province, PostalCode WS LT Ef

boty S22. 222 b cous S22. - 2:9 65

Phone Number’ : fax Number
seo. ——DtG_Ademituyi __

Physician/Provider Signature #268199

420 Columbia Streak
New Westminster BC —

NON 4-5 22-2205 Fax604 600-1006

-PART SZEMPLOYEE CONSENT = MUST BE-COMPLETED RY-THE EMPLOVE

) bautharlze the healthcare professinnal wie has signed this farm to release to BCRTC Occupational Health
aad Wellness any functional abilities, limitations and/or restrictions information relevant to my currant
absence and raturn to work. { alsa authorize my healthcare professional to release, and discuss informatian
concerning my Return to Work Plan, Furthermore, consent to receiving correspondence ralated to my
functional abilities, limitations and/or restrictions fram Occupational Health & Wallness by email, |
understend that.o copy.of this consent is as-valld os the original. This consent is valid-unless.and until
withdrawn tn writing.or | return ta work successfully. ;

Signature of Employee: Date:

a

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