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SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD ...

Surname Given names Date of birthHome address Suburb/Town Postcode Daytime phone no Postal address if different from above I declare that to the best of my knowledge the above information is true and correct and that I have made the MEDICAL practitioner completing this form aware of any MEDICAL condition that I have and drugs or medication that I consent to my MEDICAL practitioner and/or my treating specialist releasing to the Department of Planning, Transport and Infrastructure any MEDICAL information relating to my ability to drive safely. Signature Please note: Your MEDICAL practitioner has a legal obligation to inform the Registrar if they believe that a person they have examined is suffering from a MEDICAL condition such that they endanger the public if they person must not, in providing information, make a statement that is false or misleading.

FOLD FOLD IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER MR 713 08/06 (see also MR215A) Any person who drives a motor vehicle with a GVM exceeding 8000kg and-•Is aged 70 years or more •Has a medical condition or disability which may affect their ability to drive. •The licenceclasses that include these vehicles are MR; HR; HC and MC.

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