Keys to Independence (Driving Program)

I am signing up*

for myselfon behalf of someone else

Below please fill out the information of the patient to be evaluated. If you are completing the form on behalf of someone else, your contact information should go on the previous page.

Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Relationship of Contact to Patient*

Primary Care Physician*

First NameLast Name

Referring Physician*

First NameLast Name

Referring Physician Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reason for evaluation (brief reason for need and important diagnoses in medical history that could affect driving): *

Date of last seizure, skip if not applicable

Date

Visual field deficit?*

Yes (describe in the next question)No

If you answered "yes" to the previous question, describe the visual field deficit

Driver's license is active?*

YesNo

Currently driving?*

YesNo

Accidents or fender benders in last 3 years?*

YesNo

History of becoming lost or confused while driving?*

YesNo

Check that you understand the following:*

The referring physician has faxed the order to (978) 287-8177. (Not a mandatory selection)I understand that my evaluation will be located at 310 Baker Avenue, Concord, MA and not at the main hospital.I understand that completing this form only begins the process and that driving program staff will contact me to schedule an evaluation date before the evaluation is confirmed.

Keys to Independence (Driving Program)

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