Referral Form

Guidelines for Submitting a Referral

For GPs or Specialists making a referral for a driving assessment:

Please provide our team with any medical information that may be relevant to a client’s safety to drive in the form below.

If you wish to provide documents with this referral, or the practice’s referral form please email these to [email protected] once you have submitted the referral form below.

For General Public needing a driving assessment:

OTRS requires medical clearance to progress with a driving assessment. Please contact your GP or complete the referral form below.

OTRS will contact you once the referral has been received to make an appointment.

Get in touch:

Phone: 0800 687 748

Email: [email protected]

Address:

Hamilton

Suite 3, Level 1

169 London Street,

Hamilton Central, 3204

Wellington

11A Bouverie Street

Petone

Lower Hutt

Wellington, 5012

Patient Name(Required)

Street Address(Required)

Town or City(Required)

Phone Number(Required)

Additional Contact Details: (Mobile Numbers and Email Address)

Date of Birth

Diagnosis(Required)

Reason for referral (please include MOCA or MINI ACE score and current medications list) GP please email these to [email protected](Required)

Additional Comments or Concerns

GP or Specialist Name and Designation(Required)

Clinic or Practice Name(Required)

GP or Specialist email address(Required)

GP or Specialist Contact Number(Required)

Please tick if receipt of referral or a copy of the referral is required