Medical Referral Form Referral Source: Name of person completing this form*: Relationship to Client*: Self Family Physician Specialist Physician Other Healthcare Professional Family Friend Client Information: Client Last Name*: Client First Name*: Date of Birth*: Calendar Gender*: MaleFemaleNon-binaryOther Client Address*: City*: Postal Code: Client Phone*: Client Alternative Phone: Client Email: Ok to contact by e-mail: YesNo Driver's License Number: License Status*: ValidMedically SuspendedUnsure Client Mobility (select all that apply)*: Able to walk without any mobility devicesAble to walk using a cane / poleUses a manual wheelchairUses a power wheelchairUses a scooter Is the client able to transfer into/out of a car seat?*: YesNoUnsure Page Break 1Booking arrangements: To book appointment please contact*: Contact client directly Contact family member/friend to book Page Break 2Physician Information: Does the client have a family/primary physician?: YesNo Reason for Assessment: Type of assessment: Medical Driving Assessment Functional Vision Waiver Assessment Unsure Medical Driving Assessment: What is the reason for the referral*: Relevant Medical Information: List of Current Medications: Relevant Visual Conditions: 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?*: YesNoUnsure 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?*: YesNoUnsure Has the Ministry of Transportation been informed of the diagnosis?*: YesNoUnsure Has the Ministry of Transportation asked for a formal driving evaluation?: YesNoUnsure Please provide MTO # (Can be found on letter from MTO): Please let us know if you have any questions or comments related to this referral: How did you hear about us?*: I have referred before Saint Elizabeth Website Other Internet / web-search Presentation Conference Other Prefer not to say