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Get Dmv Physician Reporting Form California

Ver s License No. Date of Birth (MM/DD/YYYY) Patient s Name Last First Middle 1. Diagnosis: 2. In your opinion, will this medical condition affect the patient s ability to drive a vehicle safely? Yes* No Uncertain* *If Yes or Uncertain, please explain: 3. Status of Patient s Medical Condition(s)*: Improving Stable Worsening or Deteriorating Subject to Change *If multiple conditions exist, please describe status and prognosis. 4. How long has this person been your patient?.

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