Driving Evaluation Referral Form
When complete, please fax this form to 317-245-2476.
Attention: Senior Driving & Mobility Services
Please contact my patient, _________________________________,
By phone at ___________________________________________.
I authorize a driving evaluation and treatment for the above named client by occupational therapy practitioners at Senior Driving & Mobility Services.
I am concerned about his/her driving because of:
___ Impaired Cognition
___ Compromised physical status
___ Memory Loss
___ Coordination problems
___ Visual Deficit
___ Patient’s concern
___ New diagnosis affecting driving
___ Family member concern
___ Other ___________________________________________
Referring Physician’s Name: _______________________________
Referring Physician’s Signature: _____________________________
Office Name and address: __________________________________
Office Phone Number: ______________________
Please fax referral form to 317-245-2476. Thank you!