Medical Request For Driver Reexamination

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North Carolina Division of Motor Vehicles 
Medical Request for Driver Re‐examination 
 
This recommendation must provide specific information regarding the medical/visual condition 
and/or driving ability of the person in question and must be made only in the interest of public safety. 
Advanced age alone cannot be considered the sole reason for a re‐examination request. Based on the 
information provided, the DMV Medical Evaluation Program will investigate and take action as 
necessary. Unsigned forms will not be accepted as a proper request and will not be acted upon. Due 
to confidentiality requirements, the Program is unable to release its final recommendation to you. 
 
 
 
Sex 
Date of Birth or Approximate Age 
Name of Person Being Reported (First, 
M.I., Last) 
Drivers License Number (if available)
Street Address
City
State
Zip
The underlying medical condition or diagnosis is:
Physician Signature: ____________________________________
Phone: _____________________________, Date: ____________________
Physician
Vision Specialist
Other
 
 
Mail this to: DMV Medical Evaluation Program, 3112 Mail Service Center, Raleigh, NC 27699 
or fax to: (919) 733‐9569 

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