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Functional Driver Assesment - Medical
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CLIENT INFORMATION:
Name:
Driver's License #:
Class:
Expiry:
Ministry of Transportation File #:
Status of Driver’s License:
Valid
Suspended
Due date to submit Functional Assessment Report:
Medical Diagnosis/Reason for Medical Suspension or Review:
*
Do you wear corrective eye lenses:
Yes
No
DOB:
Gender:
Address:
Unit #:
Postal Code:
Contact #:
Email:
MEDICAL TEAM:
Family Physician Name:
Contact #:
Address:
Fax:
Treating Specialist Name:
Contact #:
Address:
Fax:
Other-Name & Designation:
Contact #:
Address:
Fax:
Submit
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