Patient Starts Form (priority)

Physical Disability Parking Placard Application

To get started on your disability placard application, fill out the required fields below and enter your physician's email address below. Once you submit your section of the form, we'll send your physician an email to finish filling out the form.

* = required field

Submit ID

Type of placard requested:*

Select Replacement Reason:*

Number of placards requested:*

Limit 1 replacement placard if lost, stolen or destroyed during the term of the original placard

I hereby make application to Service Oklahoma for a physical disability parking placard. I understand I must display the official placard on the rearview mirror upon parking. I understand the placard may only be displayed in motor vehicles either operated by me, or in which I am a passenger. I understand that any person who knowingly makes false application for a disability parking placard, or makes or allows unauthorized use thereof, is guilty of a misdemeanor and upon conviction shall be punished by a fine of $500.

Agree to terms*

I agree to the terms above

Patient Section

Applicant (Patient) Name*

First Name

Middle Name (optional)

Last Name

Date of Birth*

Patient's Mailing Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Driver License or State Identification Card Number

Patient's Email Address*

To receive an update and a copy of your application please enter your email address

Patient's Phone Number*

Signature Base64 Image

Patient's Signature*

[clear]

Use your mouse or finger to draw your signature above

Enter Your Physician's Email

Next, please enter your physician's office email below. Once you submit your form, we'll send your physician an email to fill out the rest of the form and submit your application on your behalf.

Physician's Email Address*

If you do not have your physician's email address, contact your physician's office

Note to Physician*

Please share details with your physician about why you need a disability placard

Review Application

Please confirm your information below and click submit

Type of placard requested:

{$117307901 ‪Type of placard requested:‬}

Number of placards requested:

{$117307902 ‪Number of placards requested:‬}

Applicant (Patient) Name:

{$117307906 ‪Applicant (Patient) Name‬}

Applicant's Date of Birth:

{$117307907 ‪Date of Birth‬}

Applicant's Mailing Address:

{$117307908 ‪Patient's Mailing Address‬}

Applicant's Driver's License:

{$117307909 ‪Driver's License‬}

Patient's Email Address (optional):

{$117307910 ‪Patient's Email Address‬}

Patient's Phone Number:

{$117307911 ‪Patient's Phone Number‬}

Physician's email address:

{$117307986 ‪Physician's Email Address‬}