Vision Examination Record Form

HIGH STREET ROOM 470 FAX 573 522-8174 JEFFERSON CITY MO 65105-0200 WEB SITE www. The Driver License Bureau will make a final decision concerning my eligibility for driver licensure based on all available information* Signature of Driver or Patient must be signed in the presence of physician Date MM/DD/YYYY / / Yes Distance Acuity No Are you a regular or primary eye care provider for this patient PHYSICIAN If yes how many times have you seen this patient in the past year If no are you...