Get Vision Specialist Statement Of Examination Form

This guide will assist you in accurately completing the Vision Specialist Statement Of Examination Form online. By following these steps, you will ensure that all necessary information is provided to support your medical waiver application.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the applicant's personal details. This includes the applicant's name (last, first, middle), street address, date of birth, city, zip code, state, address line 2, driver license number, and daytime phone number.
3. In the release of information section, ensure that the applicant provides their signature and the date to authorize the sharing of their medical information.
4. For the vision specialist's section, they must provide their assessment, including how long they have been treating the patient and the results of the visual acuity tests for each eye with and without lenses.
5. Address any progressive diseases by indicating if the driver has conditions such as glaucoma, diabetic retinopathy, cataracts, macular degeneration, or retinitis pigmentosa. Specify other reasons for visual impairment if applicable.
6. Complete the peripheral vision assessment. Document the horizontal fields in degrees for each eye and indicate the method used for testing.
7. Answer questions regarding the driver's recognition of traffic signals and if a periodic vision evaluation is recommended. Provide any additional comments in the space provided.
8. If applicable, fill out the section regarding the use of a bioptic telescopic device, detailing the duration of use, simulated visual acuity, and any training received.
9. Ensure the vision specialist completes the final certification section by signing, providing their printed name, professional license number, and contact information.
10. Once all sections are properly completed, save changes to the form. You may then download, print, or share the form as needed.

Complete your Vision Specialist Statement Of Examination Form online today to facilitate your medical waiver application.