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!