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Do you have any progressive or degenerative diseases of the eye Check all that apply Retinitis Pigmentosis Cataracts Glaucoma Macular Degeneration Diabetic Retinopathy 14. PHYSICIAN S STATEMENT OF EXAMINATION Clear Form Michigan Department of State P. O. Box 30810 Lansing Michigan 48909-9832 Phone 517 335-7051 Fax 517 335-2189 E-mail medicalforms Michigan.gov www. PSY/PA/NP Signature For Driver Assessment Use Only FAVORABLE RESTRICTION MUST PASS QUESTIONABLE REFER FOR REEXAMINATION NEED...
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