Referrer

BILLING CONTACT (if different than above)

INDEPENDENT ADJUSTING COMPANY (if applicable)

CLIENT INFORMATION

LEGAL REPRESENTATIVE (if different than above)

PHYSICIAN

EMPLOYER

OTHER CONTACT

DISCIPLINE

SERVICE REQUEST

SPECIALTY PROGRAMS

Comments

Client Information

Referral Source

Driver's License Information

If NO, does the client have a learner's permit?

Has the client's license ever been suspended or revoked for any reason?

Reason for seeking a driving assessment

Is the client currently taking any medication(s)?

Has the client ever had seizures or periods of blackouts?

How long has the client been driving?

Is the client currently driving?

Does the client use any mobility aids (i.e. Walker, wheelchair, etc.) or assistive devices to complete their functional activities?

Client's Family Physician's Name

The client's physician will be contacted and asked to complete a medical referral.

Has the client recently obtained an examination of your vision?

Who is the client's Optometrist/Ophthalmologist?

The client is encouraged to obtain an eye examination, if possible, prior to the driving evaluation. For any neurological related issues, they MUST obtain the eye examination prior to the office being able to book you assessment.

FINAL NOTES

An appointment cannot be booked until all forms are completed and sent back to the office by mail or fax, an appointment cannot be booked if their physician has not stated that you are medically able to participate in the driving evaluation. They are required to bring your driver's license or learner's permit with you to the examination. Failure to do so will not enable them to participate in the in-car portion of the assessment.

If their need for a driving evaluation is related to a motor vehicle accident, an OCF18 Treatment Plan will be required prior to the assessment. Our office can assist with this process following receipt of referral information.

If you have any questions or concerns regarding the above questions or about the driver rehabilitation program, please do not hesitate to call us at (519) 968-3485.

Personal Information

Driver's License Information

If NO, do you have a learner's permit?

Has your license ever been suspended or revoked for any reason?

Reason for seeking a driving assessment

Are you currently taking any medication(s)?

Have you ever had seizures or periods of blackouts?

How long have you been driving?

Are you currently driving?

Do you currently own a vehicle?

Should you successfully demonstrate the potential to drive, is this the vehicle you will be using?

Will you be adapting this vehicle if equipment if required?

Do you use any mobility aids (i.e. Walker, wheelchair, etc.) or assistive devices to complete your functional activities?

Family Physician's Name

Your physician will be contacted and asked to complete a medical referral.

Have you recently obtained an examination of your vision?

Who is your Optometrist/Ophthalmologist?

You are encouraged to obtain an eye examination, if possible, prior to the driving evaluation. For any neurological related issues, you MUST obtain the eye examination prior to the office being able to book you assessment.

FINAL NOTES

An appointment cannot be booked until all forms are completed and sent back to the office by mail or fax, an appointment cannot be booked if your physician has not stated that you are medically able to participate in the driving evaluation. You are required to bring your driver's license or learner's permit with you to the examination. Failure to do so will not enable you to participate in the in-car portion of the assessment.

If your need for a driving evaluation is related to a motor vehicle accident, an OCF18 Treatment Plan will be required prior to the assessment. Our office can assist with this process following receipt of referral information.

If you have any questions or concerns regarding the above questions or about the driver rehabilitation program, please do not hesitate to call us at (519) 968-3485.