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Pre-Assessment Form

Complete this form before booking an assessment

On completion of this form, a member of the Herts Ability team will be in touch to arrange a suitable date for your assessment.

What are you booking?

Name *

First

Last

What is your address?

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Landline Phone Number *

Mobile Phone Number *

Email Address *

Date of Birth

How did you hear about us?

What type of license do you currently have?

Full
Provisional
No license

Has anyone referred you for an assessment?

Yes
No
Not sure

Have you informed DVLA of your medical condition?

What is your medical condition?

Do you use a wheelchair?

Can you transfer into a vehicle independently?

When did you last drive?

When did you last have your vision checked?

Height (feet)

Height (inches)

Height (centimeters)

Weight (stone)

Weight (pounds)

Weight (kilograms)

Do you wear glasses or contact lenses for driving?

Would you like to drive a manual or automatic transmission vehicle?

Manual
Automatic

Do you believe that you will require adaptations in order to drive?

If you currently use adaptations to drive please list them below.

Would you be interested in a cancellation if we get one?

Which assessment centre would your assessment to take place?

Welwyn Garden City
Luton
Watford
Harlow
East London
Stotford

Booking Date and Time

Date

Time

Consent to use your Personal Data

Please tick the box provide consent for us to use your personal data. We don't pass your data on to anyone.

Your personal data is kept confidential and only used for the purposes relating to this form and in accordance with our Privacy Policy.

Phone

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Herts Ability

Suite 4, Wentworth Lodge
Great North Road
Welwyn Garden City
Hertfordshire
AL8 7SR

Registered charity No. 1059015

Contact

01707 324581
01707 371297

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