02380 554100

Online application form

If you prefer to apply online then please complete the form below and submit. We will process the application as appropriate depending on the information sent and the payment method you specify.

* indicates required fields


Section 1. Personal details


































Section 2. Consent to speak to a third party

Wessex DriveAbility will only discuss information with the applicant. However on occasion the applicant may wish for us to discuss their details with a third party.



I Consent

















Section 3. DRIVING LICENCE DETAILS

There is a provision in the law under Section 88 of The Road Traffic Act (RTA) 1988 that may allow you to drive while DVLA processes your application.

















I Consent



Yes
No



Yes


Warning

If you already hold a driving licence and you develop a medical condition that could affect safe driving, then you are legally required to inform the DVLA. We may be unable to carry out the on-road drive part of the assessment if this has not been done.




If your have informed DVLA of a medical condition or disability, what is the present situation?


















Section 4. CURRENT DRIVING DETAILS











e.g. controlling pedals or steering, looking in mirrors etc















Section 5. MEDICAL INFORMATION






































Section 6. MOBILITY DETAILS

If you receive the Higher Rate component of the Disability Living Allowance or Personal Independence Payment please call Motability on 0300 456 4566 and ask to be referred to Wessex DriveAbility for an assessment







An Electric Powered Scooter / Wheelchair
Manual Wheelchair (folding)
Manual Wheelchair (ridged)
Crutches / Stick
Walking Frame
Prosthetic Limbs















Section 7. HEALTH PROFESSIONAL DETAILS

It may be useful for your Doctor / Consultant / Health Professional to have a copy of your report.  If you would like us to send them a copy please complete the details below











Section 8. Arranging an appointment







Yes


Section 9. OTHER INFORMATION












Section 10. Declaration

By completing and returning this Application Form to Wessex DriveAbility you are giving consent to undertake a Driving Assessment. Your consent may be withdrawn at any time. Under the Data Protection Act 1998 you have the right to enquire in writing what personal information the assessment centre holds about you and subject to status, you may be supplied with a copy of this information.



Yes


I fully understand that in exceptional circumstances Wessex DriveAbility may have a Duty of Care to inform the DVLA of the findings and outcome of this assessment.

Yes









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Leornain House Kent Road Portswood Southampton SO17 2LJ
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