Type of Permit/License
Have you ever been arrested for drunk driving? (i.e, DUI or DWI)
If you have any driving restrictions, please specify.
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
Do you wear glasses or contacts?
Do you wear a hearing aid?
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?
Do you have a Case Manager?
Phone Number of Case Manager
Fax Number of Case Manager
Party Responsible for Payment*
Auto Insurance Adjuster Name
Auto Insurance Phone Number
Auto Insurance Fax Number
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? *
Is there any additional information we should be aware of?