Driving Evaluation Patient Registration

PDS Driving Evaluation Patient Registration

PROFESSIONALDRIVING SYSTEMS 5335 Far Hills Ave Suite 125, Dayton, OH 45429 937-439-4130
PDS Driving Evaluation Patient Registration Form

Evaluation will be in a PDS provided vehicle. Evaluations are 90 minutes.

A PDS Instructor (current or retired Police Officer) will evaluate patient during various driving situations. Detailed observations will be documented during the 90 minute session.

Please have doctor or Medical Professional send the medical referral prescription to Professional Driving Systems

The fee for the program is $175.00 for a 90 minute evaluation. That fee will be charged to the patient. You will be taken to a payment link upon completion of this form.

The credit card company charges a .0325% transaction fee.

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.Format: (000) 000-0000.
Patient Birthdate*

MonthDayYear
MaleFemale
Patient's Email*
example@example.com
Patient Emergency Contact Name*
Phone Number for Emergency Contact*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Driver License Number
Patient Driver License Expiration Date
Relationship of Emergency Contact Person*
Doctor or Physician's Name Or Family Referral*
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?
First and Last Name as it appears on the credit card that will be used for payment*
Should be Empty:

PDS Driving Evaluation Patient Registration