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] or fax them directly to 07 838 0152 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 Specialist to request they complete an online referral.

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

Medical Driving Assessment Referral Form

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] or fax any other relevant information to 07 838 0152(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

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Get in touch:

Phone: 0800 687 748

Email: [email protected]

Address:

Hamilton

Suite 3, Level 1

169 London Street,

Hamilton Central, 3204

Wellington

65 Waterloo Road

Hutt Central

Lower Hutt, 5010

For clinicians only:

Make a referral: