SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD ...
If you consider that your patient may be unfit to drive, please immediately return the completed certificate to Locked Bag 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977. It is recommended that you keep a copy of this form for your own records. MEDICAL PRACTITIONER’S DECLARATION (Date of Examination) (Patient’s name)
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