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Get General Information 2019-2024

Miles From Home (5-30 in 5 mile increments) Should an actual test of the patient s driving ability be administered? Should an annual medical report be required to be filed with the Division of Vehicles? This patient is capable of safely operating a motor vehicle. (Driver must be considered a safe candidate in order to request a drive test.) Does this patient require a vision exam? Yes Yes Yes No No No Yes No Name of Medical Professional & License # (Please print) Date of Examination M.

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