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Medical Referral Form

Referral Source:
Client Information:
Today
Gender*:
Ok to contact by e-mail:
License Status*:


Client Mobility (select all that apply)*:




Is the client able to transfer into/out of a car seat?*:


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Booking arrangements:
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Physician Information:
Does the client have a family/primary physician?:

Reason for Assessment:
Medical Driving Assessment:
Does the client meet the Ministry of Transportation Visual Acuity standard of 20/50 or better with both eyes open and examined together, with or without corrective lenses?*:


Does the client meet the Ministry of Transportation Visual Field standard of 120 degrees along horizontal meridian and at least 15 continuous degrees above and below fixation with both eyes open and examined together?*:


Has the Ministry of Transportation been informed of the diagnosis?*:
Has the Ministry of Transportation asked for a formal driving evaluation?: