DriveFit | Insight Driver Fitness
Fax: 1-877-807-4669

Clinical & Self Referrals

DriveFit Referral Form

Please complete all required fields below. Alternatively, download our printable PDF referral form and fax it to 1-877-807-4669.

Prefer to fax a paper form? Download the official DriveFit PDF Referral Form and fax to 1-877-807-4669.
Download PDF Form↓

* required fields

Please inform patient there is a fee for this service • Fax option: 1-877-807-4669

01. Client Information

Alternate Contact:

02. Services Requested

* Please choose at least one service

Determine Driver Fitness *

(*If cognitive concerns)

Support for returning to driving *

03. Referred By

Choose One

04. 3rd Party Insurance (if applicable)

05. Reason for Referral & Cognitive Screening

Diagnosed or suspected of:

Recent Event / Injury:

Cognitive Screen Results:

/120
/30

06. Symptom and Considerations (check all that apply)

Please wait for form submission to go through. You will receive a confirmation receipt upon successful submission.

Clinical Intake & General Inquiries

Driver Evaluations & Support for Returning to Drive

Speak directly with our driver fitness intake team at 1-888-475-4666 (Toll-Free) or submit a referral online. No physician referral is required for most programs.

Clinical Articles & Guides

Recent Articles from DriveFit

Browse all 11 articles→
Are You Fit To Drive?

Are You Fit To Drive?

Most drivers don’t even think about whether they’re mentally and physically capable of driving. But driving does require a level of ‘fitness’ to be safe on the road.

Read Article →
Driver's Medical Exam

Driver's Medical Exam

Do you have to do it? Across most of North America there’s some process for ensuring people are medically fit to drive. If you’ve been told to do a driver’s medical exam...

Read Article →