Phone: 0274-688-622
Doctor's Referral Form
How do I Refer Someone?
For Vehicle Assessment if you are intending to drive a modified vehicle or travelling as a passenger (perhaps in a wheelchair) you can complete the referral form below yourself, or a health professional can help you fill this out.
For a Medical Fitness to Drive Assessment to assess your medical fitness to drive a doctor’s referral with your past medical history is essential. You can send your doctor to this web page to fill out the form for you.
If you're stuck or have questions about the the referral form feel free to give Shelley a call on 0274-688-622.
Our online referral form uses JotForm who offer a protected 256 bit SSL (Secure Socket Layer) connection that uses a SHA256 Certificate to keep your submission safe as it is transmitted. However if you would prefer not to use the online form feel free to download our pdf referral form here, print and fill it out and return it to us in person or by email.