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.
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?
Case Manager Name and Phone Number:
Are you working with Michigan Rehab Services?
MRS Counselor 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*