MEDICAL CONDITION REPORTING FORM

For use where the Driver Licensing Authority has not requested an examination.

TO:

Office Manager - Licence Services
Department of Transport
EDS Centre,
108 North Terrace
Adelaide 5000
Ph 13 10 84
Fax (08) 8204 8308

Please address all enquiries to:

Director of Emergency Medicine, Flinders Medical Centre
ph. 8204 5511

I have examined the patient whose name, address and date of birth are set out below.

I consider this patient to be medically unfit at the present time.

I submit the following for your consideration as to this patient's fitness to hold a driver licence.

PATIENT

Mr/Mrs/Ms_________________________________________________________ (Print full name)

Date of Birth ____/______/______

Patient address__________________________________________________________________

EXAMINATION REPORT

 

 

 

 

Examination date ___/___/___

This patient is/is not aware that I have forwarded this report

 

_____________________________
Examiner's Name (print)

_____________________________
Signature of examining professional

Date ___/___/___