{loc address1} {loc city}, {loc state} {loc postalCode} {loc mainPhone} fax: {loc fax}



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{loc.logo}

{loc.name}

{loc.address1} * {loc.city}, {loc.state} {loc.postalCode}

{loc.mainPhone} FAX: {loc.fax}

{practice.webSite}
Department of Motor Vehicles

123 Drivein Way, Ste. 222

St. Paul, MN 55555

FAX: 765-123-4567


Full Name: {pat.firstName} {pat.middleName} {pat.lastName}

Address: {pat.address1} {pat.address2}

City, State, Zip: {pat.city}, {pat.state} {pat.postalCode}

Phone Number: {pat.prefPhone}

Date of Birth: {pat.dob}
Date of Last Vision Exam: {enc.date}

Visual Acuity without Corrective Lenses: 20/{test.29557.[OD Distance VA (20/)]} Right Eye; 20/{test.29557.[OS Distance VA (20/)]} Left Eye; 20/{test.29557.[OU Distance VA (20/)]} Both eyes.

Visual Acuity with Present Corrective Lenses: 20/{test.29556.[OD Distance VA (20/)]} Right eye; 20/{test.29556.[OS Distance VA (20/)]} Left Eye; 20/{test.29556.[OU Distance VA (20/)]} Both Eyes.

Visual Acuity with New Corrective Lenses: 20/{test.29580.[OD Distance VA (20/)]} Right Eye; 20/{test.29580.[OS Distance VA (20/)]}; 20/{test.29580.[OU Distance VA (20/)]} Both eyes.

Peripheral Vision, horizontal fields in degrees: {test.29563.[Test Note]}
Is this patient’s vision adequate to exercise reasonable and proper control of a motor vehicle?

____ No, reason: _________________________________

____ Yes, without corrective lenses

____ Yes, with present corrective lenses

____ Yes, with new corrective lenses
Vision Examiner Name: {prov.firstName} {prov.lastName}, {prov.credentials}

Office Address: {loc.address1}

City, State, Zip: {loc.city}, {loc.state} {loc.postalCode}

Signature: ___________________________________



Date: {gen.currDate}


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