Medical Examination Certificate

For Hackney Carriage and Private Hire Drivers

Milton Keynes Council, Synergy Park, Chesney Wold, Bleak Hall, Milton Keynes, MK6 1LY

Information Regarding the Medical Requirements of Milton Keynes Council
Milton Keynes Council must be satisfied that a person licenced as, or applying to be licensed as, a combined Hackney Carriage or Private Hire driver is “fit and proper” under the Local Government (Miscellaneous Provisions) Act 1976.
The Council therefore requires an applicant to be assessed by a medical practitioner to the National Group 2 medical standard used by the DVLA for the licencing of lorry and bus drivers.
What the applicant MUST do:
  1. Take this guide and the attached forms (the Milton Keynes Council Medical Examination Certificate and the D4 form) to a medical professional.
  2. All parts of the form must be completed when BOTH you and the doctor are present.
  3. If the Doctor is unable to complete the “Vision Assessment” you must go to your Optometrist for this to be completed.
  4. This medical form must be completed within one calendar month prior to your application if you are a new applicant OR within 1 month of your expiry date of your previous medical.
  5. It is the applicant’s responsibility to ensure that the pass/fail certificate is provided to the Council. It is not the responsibility of the Surgery/Company completing the assessment.
  6. Both the “Medical Assessment” and “Vision Assessment” declarations MUST be signed for the assessment to be deemed complete.
What the Doctor MUST do:
  1. Please arrange for your patient (the applicant) to be seen and for a FULL examination to be undertaken in line with the Group 2 medical standards.
  2. Complete ALL sections of the “D4” form.
  3. Certify that the applicant either meets or does not meet the Group 2 medical standards in the Councils “Pass/Fail” form.
  4. Note that the driver must pass both the “Health Assessment” and “Vision Assessment” if you are unable to complete the “Vision Assessment” please ONLYsign the “Health Assessment” and refer the applicant to an Optometrist to complete the assessment.
  5. Please sure that you have competed all forms.
  6. Please provide the applicant with a copy of the Pass/Fail Certificate. Please do not send this directly to the Council. The reasonability lies with the applicant to ensure that the Council are notified of the outcome and should retain the ability to decide not to provide their own personal data to the Council.
  7. Both the “Medical Assessment” and “Vision Assessment” declarations MUST be signed for the assessment to be deemed complete. Please only sign the declarations that you have been able to assess in full. If you are unable to complete the “Vision Assessment” please refer the applicant to an Optometrist for this section to be completed.

1 / YOUR DETAILS
FIRST NAME(s)
SURNAME
CURRENT ADDRESS
POSTCODE
TELEPHONE
DATE OF BIRTH / DAY / DDD / MONTH / MMM / YEAR / YYYY
2 / APPLICANT DECLARATION
I authorise my Doctor(s), Specialist(s) and Optometrist(s), to release the information contained on the enclosed D4 form, and any other reports about my medical condition to the Council.
I authorise the Council to disclose such medical information as necessary to Doctors or Paramedical staff to investigate my fitness to driver and to release to my Doctor(s) details of the outcome of my case and any relevant medical information.
I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief, they are correct.
SIGNED
PRINTED NAME
DATE
3 / DOCTOR’S DECLARATION “MEDICAL ASSESSMENT”
GP NAME
SURGERY NAME
COMPANY ADDRESS
POSTCODE / TELEPHONE
SIGNED / SURGERY STAMP
PRINTED NAME
DATE
I have completed a medical assessment if the above applicant having full regard to his/her medical history. The results are contained on the completed “D4” documents enclosed.
I consider that the applicant: / Meets / Does NOT meet
The criteria for a Group 2 vocational driver’s licence.
Before signing please ensure that you have stated whether you consider the applicant meets or does not meet the Group 2 criteria.
4 / DOCTOR’S/OPTOMOTRIST’S DECLARATION “VISION ASSESSMENT”
GP NAME
COMPANY
COMPANY ADDRESS
POSTCODE / TELEPHONE
SIGNED / SURGERY STAMP
PRINTED NAME
DATE
I have completed a medical assessment if the above applicant having full regard to his/her medical history. The results are contained on the completed “D4” documents enclosed.
I consider that the applicant: / Meets / Does NOT meet
The criteria for a Group 2 vocational driver’s licence.
Before signing please ensure that you have stated whether you consider the applicant meets or does not meet the Group 2 criteria.