Georgia Department of Driver Services Vision Form

Driver/Patient Section
Georgia Department of Driver Services

Vision Form- Online Renewal Only (64 years and older)
Last Name
First Name
Middle Initial
Address

Mailing Address

Street Address Line 2

City/ StateState / Province

ZIP Code
Customer’s Driver License Number (DL#)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby authorize my Optometrist/Ophthalmologist to complete and sign this form to provide information about my visual acuity to the Georgia Department of Driver Services (DDSrelating to the date and result of an eye examination, for the purpose of renewing or obtaining my Georgia Driver's license.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: