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Get PA DL-129 2012-2024

717) 787-9662 THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 4/13/12 Provider: For more information relating to Medical Reporting, visit http://www.dmv.state.pa.us/centers/medicalReportingCenter.shtml. PATIENT INFORMATION (Please complete this form in its entirety) DRIVER’S LICENSE NO. HEIGHT FEET SEX LAST NAME(S) EYE COLOR INCHES DATE OF BIRTH MONTH DAY JR./ETC TELEPHONE NUMBER E-MAIL (if applicable) YEAR STREET ADDRESS: P.O. Box number may be used in addition to .

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