Form HSMV72010 S "Report of Eye Examination" - Florida

What Is Form HSMV72010 S?

This is a legal form that was released by the Florida Department of Highway Safety and Motor Vehicles - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the Florida Department of Highway Safety and Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HSMV72010 S by clicking the link below or browse more documents and templates provided by the Florida Department of Highway Safety and Motor Vehicles.

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Download Form HSMV72010 S "Report of Eye Examination" - Florida

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FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
REPORT OF EYE EXAMINATION
I hereby authorize (PRINT DOCTOR’S FULL NAME)__________________________________________________________________to give me this
vision examination and to submit this report and recommendations to the Division of Motorist Services.
___________________________________________________
___________________________________________________________
Applicant’s Signature
Florida Driver License Number
______________________________________________________
___________________________________________________________
Applicant’s Address, Street & Number
City and State
CERTIFICATION OF EYE SPECIALIST
I AM LICENSED TO PRACTICE OPHTHALMOLOGY/OPTOMETRY AND CERTIFY THAT I HAVE PERSONALLY EXAMINED THE EYES OF
_________________________________________________________
OPTOMETRIST
Print Patient’s Name
Date of Birth
OPHTHALMOLOGIST
THAT A TRUE RECORD OF THIS EXAMINATION APPEARS ON THE FORM BELOW, AND THAT SAID APPLICANT SIGNED ABOVE IN MY
PRESENCE.
Exam Date__________________________________
Signature of Eye Specialist _____________________________________________________
Physician License Number _____________________
Business Address ____________________________________________________________
Form not valid after (1) year from exam date
Telephone ___________________________________
Date Corrective Lenses Issued __________________
Signature of Eye Associate _____________________________________________
Business Address ____________________________________________________
Telephone Number ___________________________________________________
DISTANT VISION ONLY
RIGHT EYE
LEFT EYE
BOTH EYES
VISION UNCORRECTED
20/
20/
20/
VISION WITH BEST
20/
20/
20/
CORRECTION
YES
NO
1.
Will lenses improve applicant’s acuity? Are they being fitted?______________________________________
2.
In your opinion, would the wearing of corrective lenses be advisable for driving purposes?
If not, why? ________________________________________________________________________________
3.
Is there evidence of eye disease or injury that would affect the driving ability? If so, please
describe:___________________________________________________________________________________
Can it be compensated for?
4.
In your opinion, should the patient be restricted to “Daylight Driving Only?”
5.
Do you recommend that a driver license be denied on visual grounds? If so, upon what grounds?
___________________________________________________________________________________________
6.
Does applicant meet the required minimum of 130 degrees of uninterrupted horizontal visual field? If not, a
charted field must be submitted. Either a Goldmann kinetic III-4e or equivalent or a Humphrey Esterman
program is required. Static automated 30 degree and 60 degree fields are NOT acceptable.
7.
Should patient have vision checked more frequently than the driver license renewal period?
If yes, medical reason must be listed: _________________________ How often?________________________
8.
On the basis of your clinical observation, visual or otherwise, do you recommend applicant be required to
pass a driving test? If yes, please explain:________________________________________________________
*NOTE: IF THERE IS ANY IMPROVEMENT WITHOUT ADVERSELY AFFECTING THE PATIENT’S CONDITION, CORRECTIVE LENSES MUST
BE WORN.
ATTENTION ALL APPLICANTS
ALL APPLICANTS WHO FAIL TO MEET MINIMUM VISION REQUIREMENTS MUST TAKE THIS FORM TO THEIR EYE SPECIALIST, AFTER
IT IS COMPLETED, THIS FORM MUST BE RETURNED TO THE DRIVER LICENSE EXAMINING OFFICE.
INSTRUCTIONS TO THE EYE SPECIALIST
All applicants for licenses and persons being re-examined are given simple vision tests by driver license examiners; but when more accurate measurements are needed,
when an improvement in vision would add to safety, or when unusual eye defects are found, the person is asked to visit an eye specialist. A report from such specialist is
particularly valuable if the fitness of a driver is questioned in court, or following a crash. In some cases, examinations by more than one specialist are requested as stated
in the next paragraph.
A difference of more than 20 points between the eye specialist’s readings and the examiner’s readings will warrant referral to a second eye specialist ONLY if that
difference results in the applicant not meeting the minimum vision standards for licensing in Florida. No recommendations or suggestions as to which specialist to visit
are given by the driver license examiners. Only reports from licensed eye specialists will be acceptable. The eye specialist assumes no responsibility in making this report
other than that of representing the facts.
FLORIDA MINIMUM VISUAL STANDARDS FOR LICENSING
All drivers are required to have the best possible vision
Worse than 20/40…In either eye, with or without corrective lenses, are referred to a licensed eye specialist for possible improvement.
20/70……………….In either eye, or both eyes together may pass with or without corrective lenses, if vision cannot be improved; however if one eye is blind or 20/200 or
worse, the other eye must be 20/40 or better.
130 degrees………..Minimum acceptable field of vision.
The use of telescopic lenses to meet visual standards is not recognized in Florida.
HSMV 72010 S (Rev 5/14), 15A-1.013, F.A.C.
FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
REPORT OF EYE EXAMINATION
I hereby authorize (PRINT DOCTOR’S FULL NAME)__________________________________________________________________to give me this
vision examination and to submit this report and recommendations to the Division of Motorist Services.
___________________________________________________
___________________________________________________________
Applicant’s Signature
Florida Driver License Number
______________________________________________________
___________________________________________________________
Applicant’s Address, Street & Number
City and State
CERTIFICATION OF EYE SPECIALIST
I AM LICENSED TO PRACTICE OPHTHALMOLOGY/OPTOMETRY AND CERTIFY THAT I HAVE PERSONALLY EXAMINED THE EYES OF
_________________________________________________________
OPTOMETRIST
Print Patient’s Name
Date of Birth
OPHTHALMOLOGIST
THAT A TRUE RECORD OF THIS EXAMINATION APPEARS ON THE FORM BELOW, AND THAT SAID APPLICANT SIGNED ABOVE IN MY
PRESENCE.
Exam Date__________________________________
Signature of Eye Specialist _____________________________________________________
Physician License Number _____________________
Business Address ____________________________________________________________
Form not valid after (1) year from exam date
Telephone ___________________________________
Date Corrective Lenses Issued __________________
Signature of Eye Associate _____________________________________________
Business Address ____________________________________________________
Telephone Number ___________________________________________________
DISTANT VISION ONLY
RIGHT EYE
LEFT EYE
BOTH EYES
VISION UNCORRECTED
20/
20/
20/
VISION WITH BEST
20/
20/
20/
CORRECTION
YES
NO
1.
Will lenses improve applicant’s acuity? Are they being fitted?______________________________________
2.
In your opinion, would the wearing of corrective lenses be advisable for driving purposes?
If not, why? ________________________________________________________________________________
3.
Is there evidence of eye disease or injury that would affect the driving ability? If so, please
describe:___________________________________________________________________________________
Can it be compensated for?
4.
In your opinion, should the patient be restricted to “Daylight Driving Only?”
5.
Do you recommend that a driver license be denied on visual grounds? If so, upon what grounds?
___________________________________________________________________________________________
6.
Does applicant meet the required minimum of 130 degrees of uninterrupted horizontal visual field? If not, a
charted field must be submitted. Either a Goldmann kinetic III-4e or equivalent or a Humphrey Esterman
program is required. Static automated 30 degree and 60 degree fields are NOT acceptable.
7.
Should patient have vision checked more frequently than the driver license renewal period?
If yes, medical reason must be listed: _________________________ How often?________________________
8.
On the basis of your clinical observation, visual or otherwise, do you recommend applicant be required to
pass a driving test? If yes, please explain:________________________________________________________
*NOTE: IF THERE IS ANY IMPROVEMENT WITHOUT ADVERSELY AFFECTING THE PATIENT’S CONDITION, CORRECTIVE LENSES MUST
BE WORN.
ATTENTION ALL APPLICANTS
ALL APPLICANTS WHO FAIL TO MEET MINIMUM VISION REQUIREMENTS MUST TAKE THIS FORM TO THEIR EYE SPECIALIST, AFTER
IT IS COMPLETED, THIS FORM MUST BE RETURNED TO THE DRIVER LICENSE EXAMINING OFFICE.
INSTRUCTIONS TO THE EYE SPECIALIST
All applicants for licenses and persons being re-examined are given simple vision tests by driver license examiners; but when more accurate measurements are needed,
when an improvement in vision would add to safety, or when unusual eye defects are found, the person is asked to visit an eye specialist. A report from such specialist is
particularly valuable if the fitness of a driver is questioned in court, or following a crash. In some cases, examinations by more than one specialist are requested as stated
in the next paragraph.
A difference of more than 20 points between the eye specialist’s readings and the examiner’s readings will warrant referral to a second eye specialist ONLY if that
difference results in the applicant not meeting the minimum vision standards for licensing in Florida. No recommendations or suggestions as to which specialist to visit
are given by the driver license examiners. Only reports from licensed eye specialists will be acceptable. The eye specialist assumes no responsibility in making this report
other than that of representing the facts.
FLORIDA MINIMUM VISUAL STANDARDS FOR LICENSING
All drivers are required to have the best possible vision
Worse than 20/40…In either eye, with or without corrective lenses, are referred to a licensed eye specialist for possible improvement.
20/70……………….In either eye, or both eyes together may pass with or without corrective lenses, if vision cannot be improved; however if one eye is blind or 20/200 or
worse, the other eye must be 20/40 or better.
130 degrees………..Minimum acceptable field of vision.
The use of telescopic lenses to meet visual standards is not recognized in Florida.
HSMV 72010 S (Rev 5/14), 15A-1.013, F.A.C.