Vision Examination Report
32-4001 R08/20
Mail Drop 818Z Medical Review Program PO Box 2100 Phoenix AZ 85001-2100
Driver Name (first, middle, last, suffix)
Date of Birth
Street Address
VISION EXAMINATION REPORT
Page 1 - Standard Vision Report
DL / Customer Number City
State Phone
(
)
State Zip
PATIENT MUST COMPLETE AND SIGN THE "MEDICAL INFORMATION RELEASE" ON THIS FORM BEFORE GIVING IT TO PHYSICIAN
Medical Information Release: I hereby authorize this physician to release to the Motor Vehicle Division any requested medical information that is pertinent to my ability to safely operate a motor vehicle.
Patient Name (or legal guardian):
Signature:
Date
MUST BE COMPLETED BY PHYSICIAN ? Examination Date
................
................
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