HTML Preview Customer Medical Report page number 1.
MED 2 (02/25/2017)
CUSTOMER MEDICAL REPORT
Describe, in detail, your medical condition.
CUSTOMER INFORMATION
Check if this is a new address, your address will be changed
on DMV's system.
GENDER WEIGHT
HEIGHT
MALE
BIRTH DATE (mm/dd/yyyy)
FEMALE
lbs FT IN
Do you take prescription/non-prescription medications?
If Yes, list below. (attach a separate sheet if more space is required)
YES NO
NON-PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN
Have you ever experienced a blackout, seizure, loss of consciousness, or syncope?
If Yes, enter date of last episode.
Did the episode result in a motor vehicle crash?
YES NO
DATE (mm/dd/yyyy)
YES NO
Purpose: Use this form to request medical information from your physician, physician assistant or nurse practitioner.
Instructions: Follow the detailed INSTRUCTIONS printed on page 2. Complete the Customer Information and Information Release
Approval sections on this page. Take the entire MED 2 and DMV letter to your physician, physician assistant or nurse
practitioner to complete the sections that pertain to your medical condition. Part F must be completed by your physician,
physician assistant or nurse practitioner. Note: Any charges related to or incurred as part of the completion of this form
are the customer's responsibility.
INFORMATION RELEASE APPROVAL
CUSTOMER SIGNATURE AND AUTHORIZATION (parent must sign for a minor)
COMMERCIAL DRIVER LICENSE DISABILITY WAIVER OR HAZARDOUS MATERIALS VARIANCE
Are you applying for a commercial driver license disability waiver or a hazardous materials variance?
If YES, a CDL Disability Waiver or Hazardous Materials Variance Application (MED 30) must also be submitted.
I authorize ________________________________________________ and/or_______________________________________________________,
a licensed medical provider to complete this Customer Medical Report, submit it to DMV and, if necessary to provide further clarification or information
to DMV about my physical and/or mental condition. I consent to DMV using this information to arrive at a decision concerning my ability to safely
operate a motor vehicle. I also authorize DMV to use the above customer information to correctly identify my records on file in accordance with the
Virginia Privacy Protection Act of 1976. I understand that Virginia Code
§ 46.2-208(b)(1) prohibits DMV from releasing medical data to anyone other
than a physician, physician assistant or nurse practitioner
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER (from your driver's license) or SSN
RESIDENCE/HOME ADDRESS
CITY STATE ZIP CODE CITY OR COUNTY OF RESIDENCE
MAILING ADDRESS (if different from above)
CITY STATE ZIP CODE DAYTIME TELEPHONE NUMBER
Explain what happened during the episode.
YES NO
DATE (mm/dd/yyyy)