DOT Physical Examination Consent
1 — Purpose of Examination
You are consenting to a DOT physical examination required to obtain or maintain a Commercial Driver’s License (CDL) or Federal Motor Carrier certification. This exam is conducted under 49 CFR Part 391.41–49 and FMCSA Medical Advisory Criteria.
2 — Examination Includes
- Complete medical history review
- Vision testing (Snellen — minimum 20/40 corrected each eye)
- Hearing assessment (forced whisper test at 5 feet)
- Blood pressure & pulse rate
- Urinalysis (glucose, protein, blood)
- Physical exam: cardiovascular, respiratory, neurological, musculoskeletal, abdominal
- Controlled substance / medication review
3 — Certification Outcomes Certification may be issued for up to 24 months. Duration may be shortened based on medical conditions. Non-certification may result if a condition is found to compromise safe driving under FMCSA standards. Payment does not guarantee certification. If you are not certified or you disagree with the examination outcome, you may seek a second opinion from another certified Medical Examiner, and for certain medical conditions you may apply to FMCSA for an exemption. Disputes about the application of FMCSA standards may be directed to FMCSA under 49 CFR §391.47. For full medical standards: www.fmcsa.dot.gov/regulations/medical
4 — Release of Information By signing this form, I authorize Vitality Urgent Care to release my examination results and medical certificate status to my current or prospective employer, the FMCSA National Registry of Certified Medical Examiners, and any federal or state agency as required by law (49 CFR §391.43). I understand that my examination findings may be reported to the FMCSA Medical Registry and may be reviewed by enforcement agencies.
5 — Disclosures & Limitations
- This exam evaluates fitness under FMCSA standards only and is not a general health assessment or substitute for primary care.
- The examining provider is a Federally-certified Medical Examiner (ME) acting under FMCSA authority, not solely as your personal provider.
- Results are reported to the FMCSA National Registry and may be accessible by DOT enforcement agencies.
- A positive finding does not automatically disqualify you — exemptions and waivers may be available.
- Falsification of medical history on this form may result in license revocation and federal penalties (49 CFR §390.35).
6 — HIPAA Notice of Privacy Practices I acknowledge that I have received a copy of the Vitality Urgent Care HIPAA Notice of Privacy Practices. My Protected Health Information (PHI) may be used or disclosed as permitted by law, including for treatment, payment, healthcare operations, and mandatory regulatory reporting to the FMCSA. A copy of the Notice is available upon request or at your facility’s front desk.
7 — Consent & Acknowledgment By checking this box / signing below, I confirm:
- I voluntarily consent to the DOT physical examination.
- I have answered all medical history questions truthfully and completely.
- I understand payment does not guarantee certification.
- I authorize release of results as required by FMCSA regulations.
- I have received the HIPAA Notice of Privacy Practices.
- I understand my options if I am not certified, as described in Section 3.
By checking this box / signing below, I confirm that I have read, understood, and agree to all terms of this consent form.
