Get Loss Of Consciousness Evaluation Form - Massrmvcom

This guide provides clear instructions on how to complete the Loss of Consciousness Evaluation Form online. By following these steps, users will ensure that the form is accurately filled out for submission to the Registry of Motor Vehicles.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient information section, including the patient's name, license number, date of birth (D.O.B.), and reported condition.
3. Provide details for question (1) by stating the exact date of the most recent episode experienced by the patient.
4. In question (2), describe the cause of the episode by specifying the type of disorder the patient suffers from.
5. For question (3), indicate the means by which the condition is controlled, including any medications used and their dosages.
6. Answer question (4) by stating the degree of disability suffered during an episode, detailing the extent of the episode.
7. In question (5), share your professional opinion regarding the probability of reoccurrence of the episode along with specific reasons for your estimate, including frequency of occurrence.
8. Select one option in question (6) to certify the patient's medical qualification to operate a motor vehicle safely, including options for further evaluation if needed.
9. If applicable, answer question (8) by indicating whether you have read the attached police report concerning the patient.
10. Provide any additional comments in question (9), if necessary.
11. Complete the physician certification section by stating your name, Massachusetts Board of Registration number, address, and signing to confirm the accuracy of the information.
12. Once all information has been entered, save changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure timely processing.