IMG_9746 - CopyInstructions on Registration:

  1. Complete registration form below.
  2. Email or fax a physician referral for a driving evaluation.  Email: • Fax: (734) 432-6007
  3. Once all the necessary documents have been received, we will contact you.

Registration Form

First Name*
Last Name*
Home Phone
Cell Phone
Street Address*
Zip Code*
Type of Permit/License
License/Permit Number
License/Permit Expiration
Have you ever been arrested for drunk driving? (i.e, DUI or DWI)
If you have any driving restrictions, please specify.
Date You Last Drove
Current Diagnosis*
List of Medications
Name of Referring Doctor
Please list any past illness, injuries, or conditions.
If you have a spinal cord injury, please indicate the level of injury (C, T, or Other).
Do you have a legal guardian?*
Guardian's First and Last Name
Guardian's Phone Number
Equipment Used
NoneBioptics (BTLS)CaneWalkerWheelchairOther (List Below)
Do you wear glasses or contacts?
Do you wear a hearing aid?
Hand Dominance
Height (ft.' in")
Weight (lbs.)
Manual Wheelchair Make/Model Number
Do you have power assist wheels?
Electric Wheelchair Make/Model Number
Electric Scooter Make/Model Number
Can you transfer from your wheelchair independently?
Type of Vehicle You Plan to Drive
Name of preferred vendor?
Have you completed your clinical evaluation elsewhere?
Are you working with Michigan Rehab Services?
Name of MRS Counselor?
Do you have a Case Manager?
Name of Case Manager
Phone Number of Case Manager
Fax Number of Case Manager
Email of Case Manager
Party Responsible for Payment*
Auto Insurance Company
Auto Insurance Claim #
Auto Insurance Adjuster Name
Auto Insurance Phone Number
Auto Insurance Fax Number
Auto Insurance Email
Auto Insurance Billing Address
Do you have coordinated benefits?
Is your case in litigation?
Name of Attorney(s) & Phone Number
Preferred Evaluation Location
How did you hear about us? *
Upload Scripts or Documents
File size must be less then 500K per document. File types are "jpg, jpeg, png, doc, docx, pdf".
File 1:

File 2:

File 3:
Is there any additional information we should be aware of?
I certify that this information is complete to the best of my knowledge. I understand that providing false information or leaving out pertinent information may compromise the quality of care I receive.*


E-Signature *
Signature Date*