REPORT OF VISION EXAMINATION
A Public Service Agency
APPLICANT COMPLETES THIS SECTION
INSTRUCTIONS: Please complete the driver license number, date of birth, telephone number, name, and address areas
of this form. You must sign and date the authorization line. All medical information received by the Department of Motor
Vehicles (DMV) is conﬁ dential under California Vehicle Code (CVC) Section 1808.5. Please bring this completed form and
any new corrective lenses with you when you return to DMV for further testing. If any section of this form is incomplete, it may
have to be returned to the vision specialist for completion. DO NOT MAIL THIS FORM BACK TO DMV unless asked to do
so by a DMV employee. Alterations or erased information may void this form.
Your vision specialist should conduct a new vision examination unless one has been conducted within the last six months.
DMV will make the ﬁ nal licensing decision based on a combination of factors, including information from your vision
DRIVER LICENSE NUMBER
DATE OF BIRTH (MO., DAY, YR.)
HOME TELEPHONE NUMBER
NAME (FIRST, MIDDLE, LAST)
I authorize the vision specialist conducting this examination to provide the Department of Motor Vehicles with the following
information for its conﬁ dential use (CVC §1808.5) in evaluating my ability to safely operate a motor vehicle.
• 20/40 with both eyes tested together, and
• 20/40 in one eye, and
DMV’s Visual Acuity Screening Standard is:
• 20/70, at least, in the other eye.
OPHTHALMOLOGIST OR OPTOMETRIST COMPLETES THOSE SECTIONS THAT APPLY —
Information must be from exam
within last 6 months.
1. REFRACTION — Complete only those sections that apply.
HAVE NEW DISTANCE LENSES BEEN PRESCRIBED AND FITTED?
DATE NEW LENSES WERE PRESCRIBED
IS NIGHT DRIVING RECOMMENDED?
IS MONOVISION EMPLOYED?
DID YOUR PATIENT RECEIVE BIOPTIC LENS TRAINING?
By contact lenses
By refractive surgery
DID PATIENT RECEIVE BIOPTIC LENS TRAINING THAT INCLUDED DRIVING?
Is best corrected visual acuity in each eye recommended for driving?
SKILL IN USING BIOPTIC TELESCOPE
Right eye 20/ ___________
Left eye 20/___________
Bioptic Telescope suitable for driving?
2. VISUAL ACUITY — Complete Clinical Measurement Section. Lenses include contact lenses or glasses.
DMV MEASUREMENT (FOR DMV USE ONLY)
CLINICAL MEASUREMENT (WITHOUT BIOPTIC TELESCOPE)
With Current Lenses
Best Corrected Visual Acuity 20/
3. DIAGNOSIS —
Please indicate vision condition by checking the box(es) representing affected eye(s). If the diagnosed condition is not listed, write the
diagnosis under “other diagnosis/comments” below.
REFRACTIVE R L
RETINAL/OPTIC NERVE R L
Decreased Peripheral Vision
Decreased Peripheral Vision. Please
identify the areas affected on the chart in
Section 5 (see reverse).
Post. Caps. Opac.
(CRVO, PRP etc.)
Other diagnosis/comments _______________________________________________________________________________________________
Monocular Vision (No Light Perception or Prosthesis) If monocular, when was the monocular vision diagnosed? ___________________________
If monocular, does the patient have a medical condition that could affect the functional eye in the future?
Any eye surgery (including refractive)?
No Date of most recent surgery ____________ Type of surgery_____________________
DL 62 (REV. 4/2007)