Form Med 3 is a document used by the Department of Motor Vehicles to collect medical information about a driver. The form can be completed by a doctor, or in some cases, the driver themselves. The information collected on Form Med 3 is used to determine whether a person is medically certified to operate a motor vehicle. completion of this form is mandatory for certain drivers, such as commercial drivers and those applying for a new driver's license.
| Question | Answer |
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| Form Name | Dmv Form Med 3 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mailing, Impaired, impairment, furnish |
MEDICAL REVIEW REQUEST
MED 3 (05/10/2013)
Purpose: Use this form to request the Department of Motor Vehicles (DMV) to conduct a medical review of a licensed driver.
Instructions: Print or type all information. Complete form in its entirety. Mail completed form to Medical Review Services at the above address, or fax to Medical Review Services at
DRIVER INFORMATION
DRIVER NAME (last, first, middle) |
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GENDER |
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BIRTHDATE (mm/dd/yyyy) |
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MALE |
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FEMALE |
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DMV CUSTOMER NUMBER |
VEHICLE PLATE NUMBER |
TELEPHONE NUMBER |
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If you change either your residence/home address or mailing address to a
RESIDENCE/HOME ADDRESS |
CITY |
STATE |
ZIP CODE |
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MAILING ADDRESS (if different from above address) |
CITY |
STATE |
ZIP CODE |
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REQUESTER INFORMATION
Based on my observation, I believe the driver named above should be given the following tests: |
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Medical Examination |
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Vision Examination |
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Knowledge Examination |
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Road Skills Test |
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I understand that the Department of Motor Vehicles may have additional requirements. |
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Describe in detail the circumstances that led to this request. Please provide as much information as possible including a description of what appears to be the driver's mental, physical or visual impairment. Use an additional sheet if necessary.
REQUESTER NAME (print) |
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REQUESTER BADGE NUMBER |
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ORGANIZATION/LAW ENFORCEMENT AGENCY NAME |
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TELEPHONE NUMBER |
FAX NUMBER |
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BUSINESS STREET ADDRESS |
CITY |
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STATE |
ZIP CODE |
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REQUESTER SIGNATURE |
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DATE (mm/dd/yyyy) |
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CONTACT INFORMATION/NOTICE
If you have questions, contact Medical Review Services at: |
Virginia Code § |
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(Voice) |
DMV will furnish the reasons for the examination, including the identity of |
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anyone who supplied information regarding fitness to drive a motor vehicle. |
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(Deaf or Hearing Impaired Only) |
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However, this law states that the DMV cannot provide the information if the |
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(Fax) |
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source is a relative or licensed medical professional treating the driver. |
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