• Driver Medical Certificate Form

    Please complete this medical intake form so a certificate can be prepared based on your health and driving fitness information.

  • Applicant Information

  • Date of Birth*
     - -
  • Gender
  • Format: (000) 000-0000.

  • Medical Fitness Information

  • General health status*
  • Diagnosed medical conditions relevant to safe driving
  • Recent surgery or hospitalization*
  • History of blackouts, seizures, dizziness, fainting, or loss of consciousness

  • Vision and Sensory Assessment

  • Does the applicant wear glasses or contact lenses?*
  • Vision status*
  • Does the applicant have any hearing difficulties?*
  • Does the applicant have any condition affecting peripheral vision or night vision?*

  • Driving Safety Declaration

  • Do you believe you are medically fit to drive?*

  • Medical Professional Details

  • Format: (000) 000-0000.
  • Examination Date*
     - -
  • Should be Empty:
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