DV-124V (Rev 1218)
Page 1 of 1
PLEASE RETURN COMPLETED
VISION FORM TO:
PH: (785) 368-8971
FAX: (785) 296-5857
STATE OF KANSAS DIRECTOR OF VEHICLES
MEDICAL/VISION UNIT
300 SW 29th ST.
PO BOX 2188
TOPEKA KS 66601-2188
KANSAS DIVISION OF VEHICLES VISION FORM
GENERAL INFORMATION & HISTORY – TO BE FILLED OUT BY THE PATIENT
DOB: Name:
Address:
Driver’s License #:
CITY/STATE/ZIP:
Phone Number:
__________________________________________________
Currently enrolled in Driver’s Education? YES / NO If yes, instructor name & phone number:
RELEASE OF INFORMATION
Permission is granted for release of all vision information concerning me to the Kansas Division of Vehicles by all medical professionals
filling out this form.
SIGNATURE OF PATIENT DATE
To the Vision Professionals: Y
ou assume no responsibility in making this report other than that of truthfully representing the facts as
they appear in your professional judgment. The information on this form must be from an examination within the last 90 days. If you
have any questions
please call (785)368-8971.
Instructions:
1. Please answer each question and fill out the entire form carefully and legibly.
2. Indicate yes or no whether from a visual standpoint only, this patient is capable of safely operating a motor vehicle.
3. Specify any driving restrictions that are appropriate based on the patient’s vision condition.
SECTION I: VISION REPORT
Acuity Right Eye Acuity Left Eye
Visual Acuity without Glasses 20/ 20
Visual Acuity with Glasses 20/ 20
Best Correction 20/ 20
Bioptic/Telescopic (for vision specialist use only) 20/ 20
Horizontal Field of Vision
Equal to or grea
No
ter than 20°?
Yes
Driver requires a Permit to test adaptive equipment. Yes No
Does this patient require a drive test? Yes No
This patient is capable of safely operating a motor vehicle. Yes No
(Driver must be considered a safe candidate in order to
request a drive test.)
An annual vision report should be required. Yes No
Does this patient require a medical exam? Yes No
Indicate below which restrictions may apply to the patient’s license if issued or continued: Maximum 6 restrictions. To remove a
restriction(s) previously requested by a physician, please check the restriction box and write “R” beside it.
Corrective Lenses
Daylight Hours Only
No Interstate Driving Outside Business Area
Within City Limits
Licensed Driver in Front Seat
Automatic Transmission Outside Mirror
Mechanical Aid Prosthetic Aid Miles From Home (5-30 in 5 mile increments)
Name of Optometrist/Ophthalmologist (Please print) Date of Examination
Address Signature of Optometrist/Ophthalmologist
Phone Date Signed
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