Fillable Form Med 4 - Customer Vision Report printable pdf download

MED 4 (08/25/2014)

CUSTOMER VISION REPORT

Purpose:

Use this form to request vision examination information from your ophthalmologist or optometrist.

DMV USE ONLY

CSC STAFF - do NOT

Instructions: Complete the Customer Information section and have your Ophthalmologist/Optometrist

send MED 4 back with

complete the Vision Examination section. The vision examination must be conducted within 90

daily work unless there is

days prior to submission of the report to DMV. Mail the completed report to the address above.

an ocular condition or

customer cannot be

Note: Any charges related to or incurred as part of the completion of this form are your

licensed due to a visual

responsibility.

defect.

CUSTOMER INFORMATION

(To be completed by customer PRIOR to vision examination)

If you change either your residence/home address or mailing address to a non-Virgina address, your driver license or photo identification (ID) card may be cancelled.

NAME (last)

(first)

(mi)

(suffix)

CUSTOMER NUMBER (from your driver license) or SSN

RESIDENCE/HOME ADDRESS

BIRTHDATE (mm/dd/yyyy)

Check if this is a new address, your

address will be changed on DMV's system.

CITY

ZIP CODE

CITY OR COUNTY OF RESIDENCE

STATE

MAILING ADDRESS (if different from above)

CITY

ZIP CODE

DAYTIME TELEPHONE NUMBER

STATE

(

)

VISION EXAMINATION (to be completed by Ophthalmologist/Optometrist)

FIRST EXAMINATION DATE(mm/dd/yyyy)

MOST RECENT EXAMINATION DATE(mm/dd/yyyy)

VISION STANDARDS

DRIVER'S LICENSE:

20/40 or better vision in one or both eyes, and

►

VISUAL MEASUREMENTS

(See Note "A" below)

100 degrees, or better, horizontal vision in one

►

RIGHT EYE (OD)

LEFT EYE (OS)

BOTH EYES (OU)

or both eyes.

Uncorrected Visual Acuity

RESTRICTED TO DAYLIGHT HOURS ONLY:

20/70 or better vision in one or both eyes, and

►

RIGHT EYE (OD) LEFT EYE (OS)

BOTH EYES (OU)

70 degrees, or better, horizontal vision.

►

Best Corrected Visual Acuity

If vision is limited to only one eye, 40 degrees or

better temporal and 30 degrees or better nasal

are required.

Horizontal Visual Field

METHOD:

GOLDMANN

HUMPHREY

OTHER

(fields must be in degrees)

COMMERCIAL DRIVER'S LICENSE:

Vision limited to one eye only (check one)

Vision in both eyes

(See Note "B" below)

20/40 or better vision in each eye

►

BOTH EYES (OU)

RIGHT EYE (OD)

TEMPORAL - OD NASAL - OD

140 degrees or better horizontal vision

►

LEFT EYE (OS)

TEMPORAL - OS

NASAL - OS

Does the patient have any ocular condition(s) that would affect the safe operation of a motor vehicle?

If YES, indicate condition:

YES

DIPLOPLIA

NYSTAGMUS

PTOSIS

AMAUROSIS

HOMONYMOUS HEMIANOPSIA (HH)

OTHER

OPHTHALMOLOGIST/OPTOMETRIST CERTIFICATION

CHECK BOX THAT APPLIES:

MEDICAL PROVIDER NAME (print)

OPHTHALMOLOGIST

OPTOMETRIST

MEDICAL LICENSE NUMBER

EXPIRATION DATE (mm/dd/yyyy)

STATE ISSUING LICENSE TO PRACTICE

BUSINESS ADDRESS

TELEPHONE NUMBER

(

)

CITY

ZIP CODE

FAX NUMBER

STATE

(

)

MEDICAL PROVIDER SIGNATURE

DATE (mm/dd/yyyy)

Visual requirements must be met without the aid of a telescopic lens. Some drivers may be granted waivers from these vision requirements.

If you are unable to meet Virginia minimum vision requirements for a commercial driver's license or instruction permit, you may apply to Medical Review

Services for a disability waiver to qualify for an intrastate only CDL or instruction permit, provided you meet the Federal Motor Carrier Safety

Regulations (FMCSR) minimum vision requirements in one eye:

At least 20/40 visual acuity, and 120 degrees horizontal vision.

If you have questions or need more information to complete this form, call Medical Review Services (804) 367-6203.