Section A.

Our company recognizes the importance of developing efficiencies in an industry that places great significance in the timeliness of our service. To achieve these efficiencies, it is crucial that we do not compromise the quality of our practice, and as such Dynamic Functional Solutions Inc. is entering into an agreement with you, our consulting evaluator, to store and use (in accordance with our privacy policy) an electronic version of your signature for the following purposes:

 

1.       Use of Electronic Signature in Final Reports

 

We are requesting your consent to insert your electronic signature into the final version of your report to be provided to the referring source. We are providing our assurance to you that your signature will be used solely for reports completed by you, and will not be included on any report, nor will any report be submitted to any referring source prior to receiving expressed consent from you or staff acting in accordance with your permission. Our company will strive to ensure that a copy of the final report submitted to a referring source will also be delivered to you as soon as possible thereafter.

 

2.       Use of Electronic Signature in Acknowledgment of Expert’s Duty Forms

 

We are requesting your consent to complete and affix your scanned signature to Acknowledgement of Expert’s Duty Forms as a result of Section 44 assessments that you have been asked to complete under the Statutory Accident Benefits Schedule (SABS). You understand that this completed Form will be provided to the requesting party, which may include insurance companies and any legal representatives acting on their behalf.

 

Section B.

 

After you have read the following statement, please sign your name below.

 

By signing below, I authorize the storage of my signature with Dynamic Functional Solutions Inc. I understand that Dynamic Functional Solutions Inc. will be using an electronic copy of my signature for the purposes indicated in Section A above either by the electronic signature pad below or by a previous electronic signature already on file.

Please note: Your consent to the above terms may be revoked at any time with written confirmation of the request.