Advance Driver Training Niagara

ADVANCE DRIVER REHABILITATION REFERRAL FORM
Burlington Location 5125 Harvester Road Unit #7 Burlington, ON L7L 5L4 Phone: 905.632.2410 Fax: 905.684.3824	St. Catharines Location 27 William Street St. Catharines, ON L2R 5H9 Phone: 905.685.5591 Fax: 905.684.3824
Please fill out the following information fields. The information you provide will be kept strictly confidential.

Client Information
Last Name
First Name
Address
City
Province
Postal Code
Phone (home)
Phone (cell / alt. #)
D.O.B.
Email address
Licence Status	Valid Suspended No Licence
Drivers Licence #
MTO Letter	If you have received a letter from the MTO, please fax a copy to us at 905-684-3824

Referral Agency Information
Name of Agency
Name of Agency Contact Person
Address
City
Province
Postal Code
Telephone #
Email address

Assessment Information
Diagnosis
Name of Diagnosing Physician
Address
City
Province
Postal Code
Telephone #
Medical History	Please fax a copy of your medical history to us at 905.684.3824. (Required)

Insurance Information
Name of Insurer
Name of Adjuster
Claim #
Date of Loss
Address
City
Province
Postal Code
Telephone #
Fax #