Proof from a Medical Practitioner
Note to medical practitioner: you are asked to endorse that the applicant has mobility problems that prevent them from using local bus services. It is expected that you will know the applicant and that you will be able to make a comprehensive assessment of their disability. If you feel that you do not know enough about this person, please refer this form to another health professional. In the event that a person’s eligibility is subsequently queried, the matter will be discussed with you further. Beyond this there is no on-going responsibility implied in supporting an application.

Name: 	 Signature:	

Date:	

Profession:		
Community Nurse	o	
Occupational Therapist	o	
Physiotherapist	o	
Doctor	o	
Health Visitor	o	

Place of Work:	

If no practice stamp is available please enclose a practice compliment slip or letterhead.