Form D4 "Ophthalmologist Examination Report" - Minnesota

What Is Form D4?

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

Form Details:

  • Released on January 1, 2010;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • 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 D4 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form D4 "Ophthalmologist Examination Report" - Minnesota

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445 MINNESOTA ST., SUITE 180
ST. PAUL, MN 55101-5180
651/ 297-5029 VOICE
651/ 297-4447 FAX
651/ 282-6555 DEVICE FOR HEARING IMPAIRED
STATE OF MINNESOTA
DEPARTMENT OF PUBLIC SAFETY
OPHTHALMOLOGIST EXAMINATION REPORT
Dear Ophthalmologist:
(Patient's name) ______________________________ who appears before you is applying to the Minnesota
Department of Public Safety for a waiver from the medical standards for intrastate school bus driver. We must have
information as to whether the patient's diabetic condition has had an effect on his/her visual health. Please examine the
patient according to the criteria listed below, and answer each question accordingly. Finally, please sign and date the
report.
Does this patient have unstable proliferative diabetic retinopathy?
YES
NO
What is this patient's distant visual acuity (Snellen)?
Left: 20/
Right: 20/
What is this patient's Horizontal Fields in Degree?
Left Eye:_______
Right Eye:_______
Both
Eyes:_________
Is this reading with or without corrective lenses?
WITH
WITHOUT
Is the patient's visual acuity stable?
YES
NO
Ophthalmologist’s name (please print)
Office/clinic name and telephone number
Signature
Date of examination
Must have been examined within preceding six months.
D4 (Ophthalmologist Examination Report 2010)
AN EQUAL OPPORTUNITY EMPLOYER
445 MINNESOTA ST., SUITE 180
ST. PAUL, MN 55101-5180
651/ 297-5029 VOICE
651/ 297-4447 FAX
651/ 282-6555 DEVICE FOR HEARING IMPAIRED
STATE OF MINNESOTA
DEPARTMENT OF PUBLIC SAFETY
OPHTHALMOLOGIST EXAMINATION REPORT
Dear Ophthalmologist:
(Patient's name) ______________________________ who appears before you is applying to the Minnesota
Department of Public Safety for a waiver from the medical standards for intrastate school bus driver. We must have
information as to whether the patient's diabetic condition has had an effect on his/her visual health. Please examine the
patient according to the criteria listed below, and answer each question accordingly. Finally, please sign and date the
report.
Does this patient have unstable proliferative diabetic retinopathy?
YES
NO
What is this patient's distant visual acuity (Snellen)?
Left: 20/
Right: 20/
What is this patient's Horizontal Fields in Degree?
Left Eye:_______
Right Eye:_______
Both
Eyes:_________
Is this reading with or without corrective lenses?
WITH
WITHOUT
Is the patient's visual acuity stable?
YES
NO
Ophthalmologist’s name (please print)
Office/clinic name and telephone number
Signature
Date of examination
Must have been examined within preceding six months.
D4 (Ophthalmologist Examination Report 2010)
AN EQUAL OPPORTUNITY EMPLOYER