Driving Evaluation Referral

PDS Driving Evaluation Referral

PROFESSIONALDRIVING SYSTEMS 5335 Far Hills Ave Suite 125, Dayton, OH 45429 937-439-4130
PDS Driving Evaluation Referral from Doctor or Other Medical Professional Personnel recommending a patient.

Evaluation will be in a PDS provided vehicle for 1 hour.

A PDS Instructor (current or retired Police Officer) will evaluate patient during various driving situations. Detailed observations will be documented during the 1 hour evaluation.

Please attach/upload the prescription to Professional Driving Systems

The fee for the program is $125.00 for a 1 hour evaluation. That fee will be charged to the patient.

No determination will be made regarding the ability of the driver to maintain their driver's license.

The written observations will be faxed/mailed to the referring physician for review.
Prior to completing the registration form, please gather/prepare the following:
- Patient Name
- Patient DOB
- Patient Phone Number
- Patient Address
- Patient Email
- Patient Emergency Contact Name & Relation to Patient
- Patient Emergency Contact Phone Number
- Doctor or Physcian's Name
- Doctor's Fax Number
- Doctor's Office Address
- Doctor's contact office Email
Upon completion of the Driving Evaluation Referral Form, PDS will contact the patient to schedule and complete the evaluation.
Patient's Full Legal Name*

First NameMiddle NameLast NameSuffix
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*
Please enter a valid phone number.
Patient Birthdate*

MonthDayYear
Patient Gender*

MaleFemale
Patient's Email*
example@example.com
Patient Emergency Contact Name*
Phone Number for Emergency Contact*
Please enter a valid phone number.
Relationship of Emergency Contact Person*
Doctor or Physician's Name*
Please upload a clear photo of the Doctor's Prescripton/Referral. *

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Doctor / Medical Professional Address (For PDS to send completed Driver Evaluation Report. It may be emailed, faxed, or sent via USPS)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctor/ Medical Professional's Fax Number
Please enter a valid phone number.
Doctor / Medical Professional's Office Email
example@example.com
Please list any information about the Patient's condition that may be important for us to know prior to the Driving Evaluation.
Do you have any additional questions / comments?
Should be Empty:

PDS Driving Evaluation Referral