2010 BC Guide in Determining Fitness to Drive

Produce my glycemic log for my doctor to review when I attend for completion of the diabetic packageforms provided to me by OSMV.Obtain and retain an initial certificate of competency in blood glucose measurement from anapproved diabetic teaching clinicI acknowledge that failure to produce my certificate of competence and glycemic log to my doctor onrequest may result in cancellation of my driver’s licence.1) I CERTIFY THAT THE STATEMENTS IN THIS REPORT ARE TRUE ANDCOMPLETE AND THAT THE INFORMATION THAT I HAVE GIVEN TO THEPHYSICIAN TO COMPLETE THE DOCTOR’S REPORT ON COMMERCIAL DRIVERWITH DIABETES ON INSULIN REPORT IS TRUE AND COMPLETE.2) I UNDERSTAND THAT INACCURATE, MISLEADING, MISSING OR FALSEINFORMATION MAY LEAD TO DENIAL OR CANCELATION OF MY DRIVER’SLICENCE.3) I AUTHORIZE THE RELEASE OF ALL REPORTS FROM MEDICAL SPECIALIST(S)PERTAINING TO DISEASE, DISABILITIES AND CONDITIONS THAT MAY AFFECTDRIVING TO THE ( OFFICE OF SUPERINTENDENT OF THE MOTOR VEHICLES.SIGNATURE:TELEPHONENO.:ADDRESS:DATE:111