Service Nova Scotia
and Municipal Relations
Rev. 08/07 REP 32
Under Section 280 of the Motor Vehicle Act the
Registrar of Motor Vehicles requires you to have this
form completed for one of the following reasons:
correspondence reporting a possible medical
condition that may affect driving has been received
from a medical professional, police agency, or other
person, it is time to review the status of a previously
identified driving-related medical condition, or
because you hold or have applied for a Class 1, 2, 3,
or 4 driver’s licence.
This form must be completed by a licenced medical
practitioner who has recently attended you and who
is familiar with your medical history.
If you have a medical condition(s) that may relapse,
recur or deteriorate, you may be required to submit
follow-upmedical reports completed by your physician.
If you have any questions please contact department
staff in the Medical Section at (902) 424-5732.
The contents of any driver record are available for
inspection by the driver.
PLEASE NOTE: Any and all costs relevant to the
completion and submission of this medical
form are the responsibility of the driver.
PART 1 – Patient Consent for Physician to Report Medical Information
________________________________ Postal Code:
Driver’s Licence Master No:____________________________________
Date of Birth: ________________________________________________
Class of licence (check one):
Telephone: Home (
) _____________ Work (
I authorize any physician, hospital or medical clinic to release to the
Department any information concerning my medical condition.
PART 2 – Vision (with or without visual correction)
A – VISUAL ACUITY
(a) for classes 3, 5, 6, 7 & 8 is visu