Application For Disabled Parking Placard/plate - Town Of Hardwick (Page 2 of 2) in pdf

Application For Disabled Parking Placard/plate - Town Of Hardwick Page 2

TO BE COMPLETED BY HEALTH CARE PROVIDER

CLINICAL DIAGNOSIS:_________________________________(Required)

DURATION (circle one): Temporary

Permanent

If temporary, please state # of months___________

PLEASE CHECK ALL THAT APPLY:

_____ Unable to walk 200 feet without assistance (clinical diagnosis MUST be completed)

_____ Legally Blind* (Cert. Of Blindness may substitute for professional certification) (*automatic loss of license)

_____ Chronic Lung Disease

Please state FEV1 test results __________O2 saturation with minimal exertion_____

Use of Portable Oxygen? Yes _________

No_____

_____ Cardiovascular Disease

AHA Functional Classification (circle one): I

III

IV*

(*automatic loss of license)

_____ Arthritis (please state type, severity, and location)_________________________________________________

______________________________________________________________________________________

_____ Loss of or permanent loss of use of a limb

Description of functional disability_____________________________________________________________

______________________________________________________________________________________

HEALTHCARE PROVIDER MUST CHECK ONE:

In my professional opinion and to a reasonable degree of medical certainty:

The above condition, or any other medical condition of which I am aware, WILL NOT IMPAIR the safe

operation of a motor vehicle.

The person applying for this permit is NOT medically qualified to operate a motor vehicle safely.

The medical condition as stated above is of such severity as to require a COMPETENCY ROAD TEST.

CERTIFICATION: (Please Print)

______________________________________________________________________________________________

Healthcare Provider's Name

Title

Mass Board of Registration. #

______________________________________________________________________________________________

Address

______________________________________________________________________________________________

Telephone Number

______________________________________________________________________________________________

Healthcare Provider's Signature

Date

-2-

M20060-0505

Application For Disabled Parking Placard/plate - Town Of Hardwick Page 2