Medical condition report form

Driver's licence number:

Date of birth (dd/mm/yyyy):

Surname:

Other names

Residential address:

Street address

City

State

Postcode

Postal address different to residential address?

Contact number:

Email address:

Do you need to wear visual aids for driving?

No Yes – A condition will be added to your driver's licence requiring you to wear visual aids when driving

Do you have any other vision or eye disorders?

No Yes – Please provide detail below

Do you have any permanent or long term mental, medical or physical conditions that have not previously been reported to Driver and Vehicle Services?

No Yes – Please provide detail below

Has there been a deterioration of your medical condition about which you have previously notified Driver and Vehicle Services?

No Yes – Please provide detail below

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