Fillable Printable Form DS-703 - Article 19-A Bus Driver's Blood Pressure Follow-Up - New York

Form DS-703 - Article 19-A Bus Driver's Blood Pressure Follow-Up - New York

ARTICLE 19-A BUS DRIVER’S BLOOD PRESSURE FOLLOW-UP

BY DRIVER’S HEALTH CARE PROVIDER

NYS DMV COMMISSIONER’S REGULATIONS PART 6.10

I, ________________________________________________________________, am acting as the above-

named bus driver’s health care provider. He/she is under my care, monitoring, and treatment (if necessary),

for high blood pressure. His/her condition is controlled by (indicate which):

www.dmv.ny.gov

DS-703 (6/15)

(Print Health Care Provider’s Name)

¨ Diet

¨ Medication (identify): ______________________________________________________________

¨ Other means (explain): ______________________________________________________________

Health Care Provider’s License or Certificate Number _______________________ Issuing State________

Health Care Provider’s Address: ____________________________________________________________

____________________________________________________________

Health Care Provider’s Phone:________________________

His/her blood pressure reading today is: Systolic: ______________

Diastolic: ______________

Health Care Provider’s Signature __________________________________________________________

BUS DRIVER’S NAME: ________________________________________________________

DATE OF BIRTH: ________________________________________________________

CLIENT/LICENSE ID NUMBER (from Driver License): ____________________________________

(Must correspond to name on driver’s license)

NOTE: This form may be used in conjunction with the Examination to Determine Medical Condition of Driver

Under Article 19-A (DS-874), or with the federal medical form if it is being used in lieu of the DS-874.

Date ____________________

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