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CUSTOMER MEDICAL REPORT - Virginia

MED 2 (11/25/2020) CUSTOMER MEDICAL REPORTD escribe, in detail, your MEDICAL condition. WEIGHT HEIGHT FTINlbsBIRTH DATE (mm/dd/yyyy) Do you take prescription/non-prescription medications? If Yes, list below. (attach a separate sheet if more space is required) YESNONON-PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN Have you ever experienced a blackout, seizure, loss of consciousness, or syncope? If Yes, enter date of last the episode result in a motor vehicle crash?YESNODATE (mm/dd/yyyy) YESNOE xplain what happened during the episode. INFORMATION RELEASE APPROVALCUSTOMER SIGNATURE AND AUTHORIZATION (parent must sign for a minor) COMMERCIAL DRIVER LICENSE DISABILITY WAIVER OR HAZARDOUS MATERIALS VARIANCE Are you applying for a commercial driver license disability waiver or a hazardous materials variance?

NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER (from your driver's license) or SSN CUSTOMER INFORMATION Purpose: Use this form to request medical information from your physician, physician assistant or nurse practitioner. Instructions: Follow the detailed INSTRUCTIONS printed on page 2. Complete the Customer Information and Information …

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