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
Date
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*

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Date*

MonthDayYear
Date
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