Form DR-11 template
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Medical Form
This document is an Initial Reporting Form for a medical evaluation of an applicant for a Mississippi driver license. The form includes sections requiring the patient's signature, personal information, and authorization for release of medical information to the Department of Public Safety. Section C explains that the examination is necessary due to Mississippi Code provisions. Section D requires the physician to report any diagnosed disorders or disabilities, including seizure history. The document also includes a waiver for certain seizure conditions. The physician's signature and contact information are required at the end.
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