< > <<File No>><<Claim #>>

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL:< >

Date/Time: < > @ < >

Report Due:<<report due date>>

Thank you for agreeing to examine this person for an <<Independent Dental Examination.>>

Please note there is a tight deadline of << deadlineDATE>>for this report.

Please note there will be a videographer / interpreter present for this appointment.

The adjuster states that:

INSERT TAST

We enclose all documentation that has been made available to us.

Please obtain a detailed history, conduct a relevant examination, review the enclosed documentation, and provide your opinion on the following points:

Does the claimant have a TMD?

If so:

Do you believe it to be solely as a result of the motor vehicle accident in which the claimant was involved?

What treatment or rehabilitation would you recommend that is attributable to the index event, and what would be its approximate cost?

What is the prognosis?

Are there any barriers to recovery?

If not, could you venture an opinion as to the cause of the claimant’s condition?

When preparing your report, could you please address it to: < > of < > and quote the above referenced claim number.

PLEASE ENSURE THAT YOUR INVOICE AND REPORT ARE SENT ONLY TO WESTERN MEDICAL ASSESSMENTS.

Thank you for providing your services in this matter.

Yours sincerely,

Western Medical Assessments Corporation

Roger Hodkinson M.A., M.B. (Cantab), FRCPC

Medical Director

RGH/sz

Encls.