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Licence / Permit type Car / Motorcycle / Light truck (LR) Bus /Truck (MR, HR, HC, MC) Marine Personal watercraft endorsement Licence / Permit status Current Applying for Variation to Signed OFFICE USE Your personal details Date of birth Surname First given name D D M M Y Y Y Y Second given name Home address Postcode Examination – to be completed by a medical practitioner You must complete this section You must complete this section Visual acuity, unaided R 6/ L 6/ Binocular 6 / Visual acuity, aided R 6/ L 6/ Binocular 6 / How long have you known/treated the patient Yes Does the patient have any of the following conditions Please cross all circles that apply and provide details in Comments section.. Visual field defect (to confrontation) The patient has seen a specialist(s) A specialist report is required Specify You must complete this section On road driving test required to determine fitness to drive Yes No Please specify reason Practitioner’s details (please use BLOCK letters or official stamp) Name of practitioner Address Postcode Restrictions should apply to patient’s driving (please specify) Further examinations required The patient is aware that this form is to be sent to VicRoads The patient is aware that if a follow-up medical certificate is required, they are responsible for sending it to VicRoads..
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