Follow the steps to fill out the Customer Medical Report online.

1. Click ‘Get Form’ button to access the Customer Medical Report and open it in the editor.
2. Begin by completing the Customer Information section. Include your name, home address, customer number or Social Security Number, birth date, gender, weight, height, and daytime telephone number.
3. In the description field, provide detailed information about your medical condition. It is important to be as thorough as possible.
4. Indicate whether you take prescription or non-prescription medications. If yes, list the dosage and times taken for each medication.
5. Respond to the questions regarding blackouts, seizures, or loss of consciousness. If applicable, include dates and explanations.
6. If you are applying for a commercial driver license disability waiver or a hazardous materials variance, please check the appropriate box.
7. Proceed to the Information Release Approval section. Here, authorize your medical provider to complete and submit the Customer Medical Report to DMV, ensuring consent for them to use your information.
8. Sign and date the form. If you are a minor, ensure that a parent or guardian signs on your behalf.
9. After filling out the form, save your changes and review the document to ensure all necessary information is accurate.
10. Download, print, or share the completed form as needed, and take the entire document to your medical provider for them to complete the relevant sections.

Start filling out your Customer Medical Report online today.