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Patient Last Name First Name Middle Initial
Street Address City State ZIP
Customer Identication Number (CIN) Date of Birth
Driver Statement of Understanding (Driver signature not required for DMV processing):
• My Physician/Ophthalmologist/Optometrist will conduct an eye examination to determine my tness to operate a
motor vehicle safely and responsibly.
• My Ophthalmologist/Optometrist will respond to any additional questions from the Department of Motor Vehicles
• I understand that this form will be considered in any decision regarding the issuance of my driver license,
pursuant to C.R.S. 42-2-111 & 42-2-112.
Signature of Driver or Patient Date (MM/DD/YY)
Instructions: use your best clinical judgment as you REVIEW AND COMPLETE ALL SECTIONS. Base severity ratings within each category on
your overall assessment of impairment relative to the driving task. Form must be completed by the Physician (MD or DO) or OD. Pursuant to C.R.S. 42-
2-112, no civil or criminal actions shall be brought against any physician, physician's assistant, or optometrist based in Colorado for providing a medical
opinion if the physician, physician's assistant, or optometrist acts in good faith and without malice.
Colorado Vision Recommendations – 20/40 or better in either eye with or without corrective lenses, and total combined horizontal eld of
vision, with both eyes, of at least 120 degrees, or if blind in one eye, at least 60 degrees in the other eye. If best visual acuity with or without corrective
lenses is worse than 20/100 in the carrier lenses, the bioptic telescope must correct the visual acuity to at least 20/40.
Examination Information (check all that apply and please do not abbreviate)
Applicant is currently being treated for one or more of the following progressive ocular condition(s):
Visual Field Decit
Does patient have visual eld decit which makes driving unsafe?
Distance Acuity Right Left Both
With Correction 20 / 20 / 20 /
Without Correction 20 / 20 / 20 /
Bioptic Lens 20 / 20 / 20 /
Horizontal Perception Fields
Pass Decient Fail
Pass Decient Fail
DR 2402 (02/20/19)
COLORADO DEPARTMENT OF REVENUE
Division of Motor Vehicles
P.O. Box 173350
Denver, CO 80217-3350
FAX: (303) 205-8301
Condential Eye Examination Report
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