IMG_9746 - CopyInstructions on Registration:

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

Registration Form

First Name*
Last Name*
Sex*
Age
Birthdate*
Home Phone
Cell Phone
Street Address*
City*
State*
Zip Code*
Email
Type of Permit/License
License/Permit Number
License/Permit Expiration
If you have any driving restrictions, please specify.
DiabetesNeuropathyOther
Date You Last Drove
Current Diagnosis*
List of Medications
Name of Referring Doctor
Guardian's First and Last Name
Guardian's Phone Number
Do you wear glasses or contacts?
Do you wear a hearing aid?
Hand Dominance
Name of preferred vendor?
Have you completed your clinical evaluation elsewhere?
Are you working with Michigan Rehab Services?
Name of MRS Counselor?
Case Manager Name and Phone Number:
Party Responsible for Payment*
If Auto Insurance Paying, please list Name, Company and Claim#:
Is your case in litigation?
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.*

YesNo

E-Signature *
Signature Date*