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 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 have doctor or Medical Professional send the medical referral 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. 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.
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.
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