Fillable Printable Form 999 - Vision Examination Record
Fillable Printable Form 999 - Vision Examination Record
Form 999 - Vision Examination Record
Form 999 (Revised 04-2014)
Mail to: Driver License Bureau Phone: (573) 526-2407
P.O. Box 200 Fax: (573) 522-8174
Visit http://www.dor.mo.gov/drivers/ for additional information.
Physician Section
Missouri Department of Revenue
Vision Examination Record
Form
999
Driver or Patient Information
Are you a regular or primary eye care provider for this patient? r Yes r No
If yes, how many times have you seen this patient in the past year? _______________
If no, are you evaluating this patient for the first time today? r Yes r No
Signature of Driver or Patient (Must be signed in the presence of physician) Date (MM/DD/YYYY)
I hereby authorize and accept that:
• My physician will conduct an eye examination to determine if my visual abilities are adequate to operate a motor vehicle safely
and responsibly.
• The Driver License Bureau will make a final decision concerning my eligibility for driver licensure based on all available
information.
____ ____ /____ ____ /____ ____ ____ ____
Remarks: (special restrictions, severity, stability, etc.)
Ofce Mailing Address City State Zip Code
Specialty License Number Phone Number Fax Number
Physician Name (Print) Signature Date (MM/DD/YYYY)
__ __ / __ __ / __ __ __ __
( _ _ _ ) _ _ _ - _ _ _ _
( _ _ _ ) _ _ _ - _ _ _ _
Last Name First Middle
_____ _____ / _____ _____ / _____ _____ _____ _____
| | | | | | | |
Date of Birth (MM/DD/YYYY) Social Security Number
Mailing Address City State Zip Code
Distance Acuity Left Right Both
W/O Correction 20/ 20/ 20/
With Correction 20/ 20/ 20/
Horizontal Field
Width
20/40 or better in either eye, or both, corrected Corrective lenses (A)
20/100 or worse in left eye only, no aid or corrected Left outside mirror (Y)
20/100 or worse in right eye only, no aid or corrected Right outside mirror (T)
20/41 to 20/59 Daylight driving only (AC)
20/60 to 20/74 Daylight driving only, restricted 45 mph (ACF)
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