Form Dl 121 PDF Details

On July 1, 2017, the Department of Motor Vehicles (DMV) will begin using a new application for driver licenses and identification cards called Dl 121. This new application is intended to make transactions faster and more convenient for customers. There are a few things you need to know about Dl 121 before applying, so keep reading to find out more. First, the new application can only be used at approved DMV locations. You cannot use it to renew or replace your driver license or ID card online. Second, you will need to provide proof of residency when you apply. This can include a current utility bill, rental agreement, or mortgage statement. Finally, if you are under 18 years old, you will need to have your parent or legal guardian sign your application form. If you have any questions about Dl 121 or the application process, be sure to speak with a DMV representative at your local office. Thanks for reading!

QuestionAnswer
Form NameForm Dl 121
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespenndot seizure reporting, penndot medical reporting form, dmv seizure form, penndot seizure reporting form

Form Preview Example

DL-121 (12-12)

SEIZURE REPORTING FORM

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

Bureau of Driver Licensing, P.O. Box 68682, Harrisburg, PA 17106-8682, (717) 787-9662

THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 11/16/2012

Provider: For more information relating to Medical Reporting, visit http://www.dmv.state.pa.us/centers/medicalReportingCenter.shtml.

PATIENT INFORMATION (Please complete this form in its entirety)

DRIVER’S LICENSE NO.

LAST NAME(S)

JR. ETC FIRST NAME

HEIGHT

SEX

EYE COLOR

 

DATE OF BIRTH

TELEPHONE NUMBER

E-MAIL (if applicable)

FEET

INCHES

 

 

MONTH

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.

CITY

STATE ZIP CODE

1.How long have you been treating the patient? _____________________________________________________

2.Did the patient have a seizure?____________________________________________________________________

If yes, date of the seizure: ________________________________________________________________________

3.Has the patient had more than one seizure? ________________________________________________________

4.Does the patient have an electrically diagnosed seizure disorder? _____________________________________

5.Has the patient had an EEG?_________ If yes, date of EEG: __________________________________________

6.Is the patient being treated with medication? _________ If yes, type and dosage:________________________

Does the medication affect the patient's ability to safely operate a motor vehicle? ______________________

7.Other than a seizure disorder, does the patient have episode(s) of loss of consciousness or awareness

that would interfere with the safe operation of a motor vehicle? _______________________________________

If yes, please explain: ____________________________________________________________________________

8.Does the patient have seizure(s) attributable to a prescribed change in or removal from medication? _____

If yes, when was the medication changed/discontinued? ____________________________________________

If yes, date of last seizure: _______________________________________________________________________

Has the original medication been reintroduced? _____________________________________________________

Page 1 of 2

DL-121 (12-12)

PATIENT NAME__________________________________ DRIVER'S LICENSE NUMBER________________

9.Does the patient have seizure(s) always preceded by a specific prolonged aura? __________________________

If yes, what is the duration of the aura? ______________________________________________________________

How is it manifested? ______________________________________________________________________________

Has the patient experienced the aura for at least 2 years? ______________________________________________

10.Does the patient experience only an aura? ___________________________________________________________

How is it manifested? ______________________________________________________________________________

Has the patient experienced only an aura for at least 2 years? __________________________________________

11.Does the patient have a pattern of seizure(s) occurring only during sleep or immediately

upon awakening?__________ Has the patient experienced this pattern for at least 2 years? ________________

12.Were the only seizure(s) the patient had within the last 6 months attributable to a nonrecurring transient

illness, toxic ingestion, or metabolic imbalance? ______________________________________________________

If yes, please explain and include dates of seizure(s): __________________________________________________

_________________________________________________________________________________________________

HEALTH CARE PROVIDER INFORMATION (Please print or type)

HEALTH CARE PROVIDER'S NAME

SPECIALTY

 

HEALTH CARE PROVIDER'S LICENSE NUMBER

 

 

 

 

 

 

STREET ADDRESS

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

 

 

 

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsiication to authorities) punishable by a ine up to $2,500 and/or imprisonment up to 1 year.

__________________________________________________________________________________

________________________________

Health Care Provider's Signature

Date

Page 2 of 2

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Stage number 1 in filling in penndot medical form

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Writing part 2 of penndot medical form

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Part # 3 in submitting penndot medical form

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Stage number 4 for filling in penndot medical form

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Guidelines on how to complete penndot medical form part 5

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