Dmv Form Dld 100 – Fill Out and Use This PDF

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		Date of Vision Examination
		(Must be within the last 90 days)
		(	)
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
	(Must be within the last 90 days)
	(	)
PRINTED Name of Physician Physician’s License Number	Physician’s Area Code & Phone No.

_________________________________________________________________________________________________

Office Address of Physician

DLD-100 (Revised 01/2009)