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Visual Examination Report Failure to return this completed form by to Department of Licensing (DOL) may result in the suspension of the driver s driving privilege. Driver/Patient information Name (Last, First, Middle) Date of birth (Area code) Daytime telephone number Driver license number Consent to release information I authorize the ophthalmologist/optometrist below to provide clarification or information regarding my visual condition based on an examination conducted within the past.

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