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Optometry Medical Certificate
Name of applicant
*
First
Last
List identification marks
click the + to add additional lines
Does the applicant to the best of your judgment readily suffer from any defect of vision?
Yes
No
Can the applicant to the best of your judgment readily distinguish the pigmentary colors red and green?
Yes
No
In your opinion, is he/she able to distinguish with their eyesight at a distance of 25 meters in good daylight a car license plate?
Yes
No
In your opinion, does the applicant suffer from a degree of deafness that would prevent his/her from hearing the ordinary sound signals?
Yes
No
In your opinion, does the applicant suffer from night blindness?
Yes
No
Has the applicant any defect, deformity, or loss of member which would interfere with the efficient performance of his duties as a driver?
Yes
No
If so, provide details of any defects or deformities:
Patient's blood type
Select one
A+
B+
AB+
O+
A-
B-
AB-
O-
Optometrist name
First
Last
Signature
*
This is a preview of this form. No submissions will be received.