Central Services and Records Division
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Rural Nevada (877) 368-7828
Website: www.dmvnv.com
Physical Evaluation Form
Driver’s License Renewal by Mail
NRS 483.383-483.384, NAC 483.420-483.455
Sections 1 and 2 must be signed and dated not more than 90 days before the date this form is submitted to the Nevada DMV. Section 1, the Vision report, must be completed, signed, and dated by a licensed ophthalmologist, optometrist, or physician. Section 2, the Medical report, must be completed, signed, and dated by a licensed physician. Please return this Physical Evaluation Form with your application and fees payment to renew your driver’s license by mail. Unless otherwise instructed, all parts of this form must be completed in full to avoid any delays of your renewal.
Please clearly PRINT the following information:
Driver’s Name _____________________________________________________________________________________
Address __________________________________________________________________________________________
Driver’s License Number _______________________ Date of Birth ______________________ Age
Section 1 – Vision (must be completed by licensed ophthalmologist, optometrist or physician)
|
Without Corrective Lenses |
With Corrective Lenses |
Right Eye |
20/ |
20/ |
Left Eye |
20/ |
20/ |
Both Eyes |
20/ |
20/ |
Does this person have a progressive disease or condition of the eye? |
......................................................... |
Yes |
No |
_______________________________________________________ |
________________________________ |
Signature of Licensed Ophthalmologist, Optometrist, or Physician |
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Date of Vision Examination |
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|
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(Must be within the last 90 days) |
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|
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( |
) |
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PRINTED Name of Ophthalmologist, Optometrist, or Physician License Number |
Area Code and Phone Number |
_________________________________________________________________________________________________
Office Address of Ophthalmologist, Optometrist, or Physician
Section 2 - Medical (must be completed by a licensed physician)
Does a medical condition exist that would prevent this patient from operating a motor vehicle safely?........ Yes No
If “Yes,” please explain: _____________________________________________________________________________
Is this patient taking any medication that would affect his/her ability to drive safely? .................................... Yes No
If “Yes,” please explain: _____________________________________________________________________________
Signature of Licensed Physician |
Date of Medical Evaluation |
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(Must be within the last 90 days) |
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( |
) |
PRINTED Name of Physician Physician’s License Number |
Physician’s Area Code & Phone No. |
_________________________________________________________________________________________________
Office Address of Physician
DLD-100 (Revised 01/2009)