NORTHWEST DRIVER REHAB REFERRAL FORM

Fill out this form and click the submit button or print the form and fax it to 425-373-1320. Please fax or mail other relevant reports that will be helpful in preparing for the evaluation.

Client Information













Referral Contact Information (if different)






Medical Information



Corrective Lenses for driving?


Seizure free for 6 months?





Mobility

Walks unassisted:


Walks with walker or cane:



Uses Wheelchair:


Transfers to vehicle:


Model and year of vehicle (if applicable)



Comments