Free Download Florida DMV Medical Reporting Form

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Free Download Florida DMV Medical Reporting Form

The reports authorized by this 6 (2), (3), Florida Statutes sectionshall be confidential… No civil or criminal action may be brought against any physician, person or agency who provides the information herein.

When reporting an individual whose driving ability is questionable due to some physical or mental impairment, please complete as much of the information listed below as possible:

  • Name:
  • Date of Birth:
  • Address: City:
  • Male
  • Female
  • Zip Code:

Free Download Florida DMV Medical Reporting Form

Download 72190.pdf (110KB)

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