Dmv Vision Form – Fill Out and Use This PDF

The DMV Vision Form is a document that you can use in order to register your glasses or contact lenses. It's important that you fill it out because if you were caught without the form, there would be more trouble on your hands.

By clicking on the orange button below, you will launch our PDF editor that allows you to edit this form quickly and efficiently. The tool is meant to help you to edit any PDF you might need through our multi purpose toolbar. It can be done on pretty much any platform, anytime!

Dmv Vision Form PDF Details

When you go to the DMV, you have to take a vision test. The test is simple - all you have to do is read some letters on a chart. But what if you can't see the letters? The DMV has a form that allows you to indicate this fact. The form is called "DMV Vision Form." You don't need it if your vision is 20/40 or better in both eyes with or without glasses or contact lenses. If it's not, fill out the form and bring it with you to the DMV. Your driver's license will be issued with the notation "Must wear corrective lenses.

You can find additional information relating to the dmv vision form by checking out the listing we compiled for you.

Question	Answer
Form Name	Dmv Vision Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	dmv vision examination, ca dmv vision form, dmv ca gov form dl62, ca dmv form dl 62

Form Preview Example

STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES®

A Public Service Agency

962

REPORT OF VISION EXAMINATION

SECTION 1 — APPLICANT COMPLETES THIS SECTION

INSTRUCTIONS: Please complete the driver license number, date of birth, telephone number, name, and address areas of this form. You must sign and date the authorization line. All medical information received by the Department of Motor Vehicles (DMV) is conidential under

California Vehicle Code (CVC) §1808.5. Please bring this completed form and any new corrective lenses with you when you return to DMV for further testing. If any section of this form is incomplete, it may have to be returned to the vision specialist for completion. DO NOT MAIL THIS FORM BACK TO DMV unless asked to do so by a DMV employee. Alterations or erased information may void this form.

Your vision specialist should conduct a new vision examination unless one has been conducted within the last six months. DMV will make the inal licensing decision based on a combination of factors, including information from your vision specialist.

DRIVER LICENSE NUMBER

NAME (FIRST, MIDDLE, LAST)

DATE OF BIRTH (MO., DAY, YR.)

HOME TELEPHONE NUMBER

()

RESIDENCE ADDRESS

CITY

STATE

ZIP CODE

I authorize the vision specialist conducting this examination to provide the Department of Motor Vehicles with the following

information for its conidential use (CVC §1808.5) in evaluating my ability to safely operate a motor vehicle.

APPLICANT’S SIGNATURE

DATE

	•	20/40 with both eyes tested together, and
DMV’s Visual Acuity Screening Standard is	•	20/40 in one eye, and

• 20/70, at least, in the other eye.

SECTION 2 — OPHTHALMOLOGIST OR OPTOMETRIST COMPLETES THOSE SECTIONS THAT APPLY — Information must be from exam within last 6 months.

1. REFRACTION — Complete only those sections that apply.

HAVE NEW DISTANCE LENSES BEEN PRESCRIBED AND FITTED?

Yes

No If yes:

Glasses

Contact Lenses

DATE NEW LENSES WERE PRESCRIBED

IS NIGHT DRIVING RECOMMENDED?

Yes No

IS MONOVISION EMPLOYED?								DID YOUR PATIENT RECEIVE BIOPTIC LENS TRAINING?
By contact lenses	Yes	No						Yes	No	Not Known
By refractive surgery	Yes	No
By refractive surgery	Yes	No						DID PATIENT RECEIVE BIOPTIC LENS TRAINING THAT INCLUDED DRIVING?
Is best corrected visual acuity in each eye recommended for driving?						Yes	No	Yes	No	Not Known

Bioptic Telescope	Right eye 20/ ___________				Left eye 20/___________			SKILL IN USING BIOPTIC TELESCOPE
Bioptic Telescope	Right eye 20/ ___________				Left eye 20/___________
Bioptic Telescope suitable for driving?			Yes	No				Satisfactory		Unsatisfactory	Not Known
Bioptic Telescope suitable for driving?			Yes	No

2. VISUAL ACUITY — Complete Clinical Measurement Section. Lenses include contact lenses or glasses.

DMV MEASUREMENT (FOR DMV USE ONLY)				CLINICAL MEASUREMENT (WITHOUT BIOPTIC TELESCOPE)

	Both Eyes	Right Eye	Left Eye		Both Eyes	Right Eye	Left Eye

Without Lenses	20/	20/	20/	Without Lenses	20/	20/	20/

With Current Lenses	20/	20/	20/	With Lenses	20/	20/	20/

				Best Corrected Visual Acuity	20/	20/	20/

3.DIAGNOSIS — Please indicate vision condition by checking the box(es) representing affected eye(s). If the diagnosed condition is not listed, write the diagnosis under “other diagnosis/comments” below.

REFRACTIVE R L DEVELOPMENTAL

Astigmatism	Amblyopia
Hyperopia	Strabismus
Myopia	Congenital Nystagmus
	Albinism

R L OPTICAL	R L RETINAL/OPTIC NERVE R L
Cataract	Diabetic Retinopathy
Corneal Opacity	Macular Degeneration
Diplopia (uncorrectable)	Glaucoma
Keratoconus	Retinal Detachment
Aphakia	Retinitis Pigmentosa
Pseudophakia	Retinal Damage
Post. Caps. Opac.	(CRVO, PRP etc.)

VISUAL FIELDS	R L
Decreased Peripheral Vision
Hemianopia
Quadrantanopia

Decreased Peripheral Vision. Please identify the areasaffectedonthechartinSection5(seereverse)

Other diagnosis/comments

Monocular Vision (No Light Perception or Prosthesis)			If monocular, when was the monocular vision diagnosed?
If monocular, does the patient have a medical condition that could affect the functional eye in the future?					Yes	No
Any eye surgery (including refractive)?	Yes	No	Date of most recent surgery	Type of surgery

DL 62 (REV. 4/2016) WWW	DL62

Name:

DL/ID/X #:

4. PROGNOSIS

Diagnosis		Static
Diagnosis		Static
Diagnosis		Static

Progressive	Stable since	(date)
Progressive	Stable since	(date)
Progressive	Stable since	(date)

WHEN SHOULD DMV REQUIRE A NEW DMV VISION EXAMINATION REPORT FORM BE SUBMITTED?

Not applicable 1 year 2 years 5 years Other

5.VISUAL FIELDS — If vision is not correctable to 20/40 in each eye, or there is possible visual ield loss, a full visual ield examination (con- frontation is permissible) must be performed. Show the approximate peripheral extent and any scotomas in the diagram below.

	LEFT EYE	RIGHT EYE
Extent:			Extent:
Left			Left
Right			Right
Up			Up
Down			Down

6.VISUAL ABNORMALITIES — The following information will help our examiners evaluate your patient’s ability to safely operate a motor vehicle. Based upon your testing, clinical impression, or knowledge of the disorder, please indicate the severity of any of the following visual abnormalities which your patient may be experiencing. Indicate severity of condition by placing a 1 (mild), 2 (moderate), or 3 (severe) in the box(es) below.

R L

Decreased Acuity

Color Defect

R L

Visual Field Loss

Reduced Depth Perception

R L

Contrast Sensitivity Loss Abnormal Eye Movements

R L

Problems With Glare

R L

Poor Night Vision

7. ADVICE — Have you given your patient any advice about driving?

Yes

If yes, please explain in #8 below.

8.ADDITIONAL COMMENTS — Report any additional information or comments you feel DMV should know concerning your patient’s visual and perceptual capabilities relating to driving performance. You may use an additional sheet of paper to provide this information as well as

information about any existing conditions which contribute to poor night vision or poor depth perception, etc. Any recommendations about the patient’s general safety should also be made. DMV will make the inal licensing decision based on a combination of factors, including your professional expertise.

9. SIGNATURE — This section must be completed to validate this report.

PRINTED NAME				M.D. OR O.D. LICENSE NUMBER

SIGNATURE				DATE OF EXAM (MUST BE WITHIN LAST 6 MONTHS)
X
ADDRESS	CITY	CA	ZIP CODE	TELEPHONE NUMBER
				(	)

DL 62 (REV. 4/2016) WWW

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entering details in california dmv vision form part 1

Type in the essential data in DMV MEASUREMENT FOR DMV USE ONLY, CLINICAL MEASUREMENT WITHOUT, Both Eyes, Right Eye, Left Eye, Both Eyes, Right Eye, Left Eye, Without Lenses, With Current Lenses, Without Lenses, With Lenses, Best Corrected Visual Acuity, DIAGNOSIS Please indicate vision, and write the diagnosis under other section.

Filling out california dmv vision form step 2

The program will ask for further details in order to quickly complete the section Name, PROGNOSIS, Diagnosis, Diagnosis, DLIDX, Static, Static, Progressive, Stable since, Progressive, Stable since, Diagnosis WHEN SHOULD DMV REQUIRE, Static, Progressive, and Stable since.

Completing california dmv vision form step 3

The Decreased Acuity Color Defect, Reduced Depth Perception, Contrast Sensitivity Loss Abnormal, ADVICE Have you given your, Yes, If yes please explain in below, ADDITIONAL COMMENTS Report any, SIGNATURE This section must be, and MD OR OD LICENSE NUMBER area will be your place to add the rights and responsibilities of each side.

california dmv vision form Decreased Acuity Color Defect, Reduced Depth Perception, Contrast Sensitivity Loss Abnormal, ADVICE Have you given your, Yes, If yes please explain in below, ADDITIONAL COMMENTS Report any, SIGNATURE This section must be, and MD OR OD LICENSE NUMBER fields to fill out

Finish by reviewing the next sections and submitting the suitable details: SIGNATURE X ADDRESS, CITY, ZIP CODE, TELEPHONE NUMBER, DATE OF EXAM MUST BE WITHIN LAST, and DL REV WWW.

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