When complete, please fax, email or send to us.  317-489-0804 office       317-245-2476 fax  

Driving Evaluation Referral Form

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 the above fax #. Thank you!