Louisiana's Office of Motor Vehicles issues this form to a driver or applicant whose vision needs an eye doctor's review. The OMV section at the top notes why it was issued and the office's own acuity readings. The optometrist or ophthalmologist then records acuity and fields and gives an opinion on driving from a vision standpoint, which the OMV uses as a guide for its decision.
OMV staff fill in the top section, the patient signs the release on page 2, and the optometrist or ophthalmologist completes every part marked 'To be Completed by Optometrist or Ophthalmologist', including the signature.
Download the current version from the source each time; forms change without notice.
Vision Examination Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Two time limits apply. The driver must return the completed form within 30 days of the 'Date Issued' entered by the OMV, or driving privileges are suspended. Separately, the form is considered valid only if the date of the eye doctor's signature has not exceeded 60 days.
Only an optometrist or ophthalmologist. They complete the acuity grid, peripheral field angles, five yes/no questions and the opinion on whether, from a vision standpoint, the patient can safely drive. The patient signs a release allowing the findings to go to the Department of Public Safety and Corrections.
The form tells the applicant that failing to return it within 30 days of the date issued results in suspension of driving privileges, and the OMV can tick a box noting the applicant did not comply. A returned report serves as a guide for the OMV's final decision on the pending application.