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Sician and your physical examination MUST have been completed within the past 12 months. PATIENT INSTRUCTIONS Please print in black ink or type: 1. 2. 3. Complete this page of the Report. Date and sign this page in the spaces provided below. Have your physician complete pages 2 through 4 and either mail or fax (with coversheet) this form directly to: Department of Driver Services c/o Driver s License Medical Unit P. O. Box 80447 Conyers, Georgia 30013 or Fax to (770)344-3629 PATIENT INFORMATI.

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