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 |
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 ___/___/___