NC INJURY LAW LLP

135 Taylor Road Ned College

Niagara-on-the-Lake ON L0S 1J0 Email: ned@nclaw.ca
Tel: (905) 555-5555 Fax: (905) 999-9999
______________________________________________________________________________

DIRECTION RE: PERSONAL HEALTH INFORMATION

TO: Dr. Gus Fring

50 Healing Road
Fort Erie ON L2E 8D8

RE: WALTER WHITE

Date of Birth: March 5, 1965

I, WALTER WHITE, the undersigned, do hereby authorize and direct you to release to my
lawyer, NED COLLEGE, of the law firm of NC INJURY LAW LLP, 135 Taylor Road, Niagara-on-
the-Lake, ON L0S 1J0, any and all personal health information that my lawyer may require in
connection with my mental and physical condition and injuries sustained including, but not limited to,
all x-rays, hospital records, medical reports, progress notes, reports of diagnostic tests, counsellors'
notes, nurses' notes, clinical notes and records from 5 years prior to December 25, 2019, medical
opinions and/or any other knowledge or information which you may possess.

I understand that my lawyer, NED COLLEGE, requires my personal health information so that
he may properly act on my behalf, including, but not limited to, analyzing and assessing damages and
liability, negotiations and settlement discussions, and the conduct of any Action or Proceeding as may
be required. I further understand that in order to properly act on my behalf, such personal health
information may be filed in Court, may be disclosed to opposing Insurers (through their adjusters or
legal counsel), or may be otherwise disclosed as required by law or the Rules of Civil Procedure. It has
been explained to me, and I understand that by granting this authorization and direction, I am
consenting to the use of my personal health information as described above.

FOR SO DOING, let this be your good and sufficient authority.

Dated on the 5th day of January, 2020, in Niagara-on-the-Lake, Ontario.

__________________________ ___________________________________
Witness WALTER WHITE