The number of pages within the document is: 2
The self-declared author(s) is/are:
Steve McCarthy
The subject is as follows:
Original authors did not specify.
The original URL is: LINK
The access date was:
2019-02-16 14:11:00.004074
Please be aware that this may be under copyright restrictions. Please send an email to admin@pharmacoengineering.com for any AI-generated issues.
Loading...
Reload document 
Open in new tab The content is as follows:
Class D and M Vision Screening Certificate p.1 MAB102 _0318 This form must be completed by an ophthalmologist or by an optometrist who is licensed to practice in the Commonwealth of Massachusetts. A. Applicant Information Last Name First Name Middle Name Suffix Massachusetts Phone # Signature: __________________________ Date: _______________ B. Vision Screening Data With Bioptic Telescope 1. Visual Acuity (Snellen) Without RX With RX (Class D Licenses Only) Right Eye (OD) 20/___ 20/___ 20/___ (through telescope) Left Eye (OS) 20/___ 20/___ 20/___ (through carrier lens) Both Eyes (OU) 20/___ 20/___ 20/___ (through other lens) Do NOT use qualifiers such as + or 2. Total Horizontal Visual Field Both Eyes Combined: ___________ (Record in Degrees). **Suggested Target size to be used: 10mm 3. Are glasses and/or contact lenses needed for driving? . ……………………………………………………………………………………………………….. Y es No 4. Are bioptic telescopic lenses needed for driving? …………………………………………………………………………………………………………………. Y es No a) b) If yes, the bioptic telescope: Is Monocular? ……………………………………………………………………………………………………………………………………………………… Y es No Is Fixed focus? ……………………………………………………………………………………………………………………………………………………. Y es No Is NO greater than 3X? ………………………………………………………………………………………………………………………………………… Y es No Is Spectacle-mounted and an integral part of the lens? ……………………………………………………………………………………………… Y es No Does not occlude the line of sight or other eye? ……………………………………………………………………………………………………….. Y es No Question # 4b. 5. ion characterized by Unresolved Diplopia?. …………………………………………………………………………………………….. Y es No NOTE: in Question # 5. 6. Can the applicant distinguish red, green, and amber colors? …………………………………………………………………………………………………. Y es No Listed below are the conditions, treatment, or medication plan which the applicant must follow in order to maintain the validity of my professional opinion: _______________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ A license is valid for five (5) years. Do you think that the applicant should be re-evaluated by the Registry during that time period? …….. Y es No -evaluation on __________ (month/year) due to __________________________________________________ (condition/ disease) and _______________________________________________________________________________________________
Please note all content on this page was automatically generated via our AI-based algorithm (4RriHsLw2tfWFlYeOqCY). Please let us know if you find any errors.