Northwest Driver Rehab

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