< >Our File:<<File No>>Claim Number:<<Claim #>>

Insurance / Legal

Delivered by courier

<

<

<<CITY/PROV>>

< >

Dear <

RE: < > < >

DOB:< >

DOL:< >

Date/Time: <<DATE >>@ < >

Report Due: <<report due date>>

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

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

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

Please obtain a detailed history, review the enclosed documentation, perform an appropriate examination, and provide your opinion with respect to the attached Letter of Instruction dated LOI DATE from our client, < > of < >,. Please respond in a question and answer format.

Please obtain a detailed history, review the enclosed documentation, perform an appropriate examination, and provide your opinion on the following points:

-

-

-

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.