You can submit your details direct by completing the form below
Please complete all boxes before submitting
Doctor / Consultant /Health Professional Name
Doctor / Consultant /Health Professional Address
Section 1. Personal details
Title
First Name
Surname
Address
Post code
Contact Tel
Email
Date of birth (dd/mm/yy)
Your weight
Your height
Prefered centre
Who is paying for the assessment?
How did you hear about us?
As part of our aim to reach everyone in the community, it would help us if you could tick one of these boxes for monitoring purposes:
Section 2. NATURE OF DISABILITY OR PROBLEM(S)
In your own words please specify your disability or problems:.
Are you on any medication?
If YES state details
Section 3. MOBILITY DETAILS
Can you walk at all?
If so, how far?
Do you require any aids when walking?
Do you use a mobility scooter or wheelchair?
If YES, can you get in / out of your wheelchair unaided?
If YES, are you able to load your wheelchair into a vehicle without difficulty?
Do you receive the Higher Rate Mobility Component of the Disability Living Allowance?
Section 4. DETAILS OF AIDS AND EQUIPMENT
If you have a scooter or wheelchair that you wish to carry with you in your vehicle, please give as many details as you can such as manufacturer, make and type.
Please give details of any other equipment such as walking aids that you will need to take with you in your vehicle.
Section 5. TRANSFER ISSUES
Have you been assessed by a Mobility Centre before?
If YES, which centre did this take place?
If you currently have a vehicle that you travel in please can you give details such as manufacturer, make and number of doors and state what problems you are having with your transfers
What do you hope to achieve from the Assessment?
Section 6. APPOINTMENT PREFERENCE
We will contact you to arrange an appointment in due course if not already arranged. In order to assist us, do you have any specific days / dates or times that you are NOT available
How to Pay
By Cheque
You can pay by cheque made payable to 'Wessex DriveAbility', please write your name and address on the reverse and send your cheque to Wessex DriveAbility, Leornain House, Kent Road, Portswood, Southampton, SO17 2LJ.
Pay Online
You can pay online via PayPal (please note there is a £2.75 administration fee to use this payment method). Simply click on the 'Pay Online' tab.
Declaration: I declare that I have checked the details I have given on this form and that they are correct to the best of my knowledge
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.
It is important to tick the following statement:
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.
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.
Please complete all boxes before submitting