@ Exhibit R — ForeMed disclosure to BCRTC, Mar 26, 2026, blank consent field, p.4
(Ademiluyi_Hotand.pdf).

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

tty pba G NE,
OR Ceoerose Pees Fane
Aameced Attending Physktin/Provider (ptease peice) Specialty (itapplicable) & Registration Nunvsar

28 CILAMBID Spe el ro BO NIC Wwe oT at,
“Wie IN ee RE Te

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bot 92. Wob ote S22. 7-296
Phone Suaber

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can Provider Serature

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EpaRTa: EMPLOYEE CONSENT = MUST.BE COMPLETED BY.THE EMPLOYEE.

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lauthaftre the healthcare professianai vhs has signed ifts form to release te BORIC Occagaticnst Heaih |
sad Welmess acy funeucnal abEtes, fimisrions ans/orsesyeictsns information relavantta my airrent i
adsence and ferctn ta work. tals aviharhe my healincare professional to teieaje; and discussinformation. |
cunterning my Return 10 Werk Flan: Forthecminie,? Consett to recehing eorrksnohideriee tetated to my j
functional aktities, imitations and/ar restrictods from Occupational Hzalth Bi Wetinass by eal: +
understand thata copy of thls corsant is'as val! asthe exeieal This consent is val'd unless and ung |

withdrawn In veriting Se Pretura mn work succrsifety.

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| Signature of Empoyee: Dace,

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Pepracte

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