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

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

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In my opinion the person who is the subject of this report: Further comments on medical condition(s) affecting safe driving are attached. Medical Practitioner’s signature Date Medical Practitioner’s name Provider Number Practice Address Telephone Number Facsimile Number E-mail Address Meets the relevant medical standard

  Report, Medical, Driving

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