Transcription of Visual Examination Report - Wa
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Visual Examination Report - Wa
XXX Visual Examination ReportFailure to return this completed form by to Department of Licensing (DOL) may result in the suspension of the driver s driving informationName (Last, First, Middle)Date of birth (Area code) Daytime telephone number Driver license number Consent to release informationI authorize the ophthalmologist/optometrist below to provide clarification or information regarding my Visual condition based on an Examination conducted within the past year. I understand the Department of Licensing will use this information to arrive at a decision regarding my ability to safely operate a motor vehicle.
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
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