MEDICAL CONDITION REPORTING FORM
For use where the Driver Licensing Authority has not requested an examination.
|Office Manager - Licence
Department of Transport
108 North Terrace
Ph 13 10 84
Fax (08) 8204 8308
Please address all enquiries to:
Director of Emergency Medicine, Flinders Medical Centre
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.
Mr/Mrs/Ms_________________________________________________________ (Print full name)
Date of Birth ____/______/______
Examination date ___/___/___
This patient is/is not aware that I have forwarded this report
Examiner's Name (print)
Signature of examining professional