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Charity Referral Form

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    Patient Details

    Alternative Contact Details

    Referrer

    GP Details

    (if no, please provide details as to why) Please note if your patient isn’t ready for an assessment within the next 3 months you will need to refer them nearer the time.

    Licence Status

    PLEASE NOTE THE PATIENT MUST HOLD A VALID LICENCE TO HAVE A DRIVING ASSESSMENT

    (please ensure your patient has informed the DVLA of any notifiable condition)

    Please advise your patient that if they do not meet the visual standard for driving (reading a number plate at 20 meters) the DVLA will be informed, and this could likely result in their licence being revoked)

    Medical Condition

    If a health professional has advised your patient to stop driving, unfortunately we will not be unable to conduct an assessment without their agreement.

    Please note, if you patient isn’t ready for an assessment within the next 3 months, you will need to refer them closer to the time.

    Referral for

    Booking Information

    Upon receipt of your referral RDAC will contact your patient to arrange an appointment

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    0300 300 2240

    feedback@rdac.co.uk

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