The information that you provide here will be populated into the official MCSA-5875 Medical Examination Report Form (the Long Form) and sent securely to our clinic after you submit it.

You can Save and then Resume this Form at any time by clicking on the "Save" button at the end of the Form. Our Provider will go over the Form with you and complete a Physical Exam when you arrive at our clinic.

You can also download the MCSA-5875 Form here as provided by the FMCSA.

 

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.