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Referral For Assessment of Fitness To Drive - Perth

Patient Name *

Patient Surname *

Date of Birth *

Address

Telephone *

Driving Status

Contact (If Other Than Patient)

Relationship

Telephone

Referred By *

Address

Telephone

Fax

Preferred Report Format

Reason For Referral *

Other Relevant Medical History

Please Check The Following Referral Guidelines * Primary concern is cognitive impairment & only minor physical
Patient is aware that there is a cost involved for the assessment (Please see fee schedule for details)

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In Australia, 42% of men with probable dementia and 63% with possible cognitive impairment are current drivers (Ross, 2009)

Referral For Assessment of Fitness To Drive - Perth

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