Attachment_II.pdf

(THIS FORM IS SUBJECT TO THE

PRIVACY ACT OF 1974 -

Use DD Form 2005.)

FRAME

EYEWEAR

PRESCRIPTION

DATE ORDER NUMBER

TO: (Lab) FROM:

NAME (Last, First) GRADE

ADDRESS/UNIT

AD NG A CGNOTHER* AF PHS

PATIENTCLINIC

SHIP TO:

SPHERE CYLINDER AXIS DECENTER H PRISM H BASE

R

L

MULTIVISION

NEAR ADD SEG HT TOTAL DECENTER

R

L

SPECIAL COMMENTS/JUSTIFICATION (*Use this space to specify blocks marked "Other.")

PRESCRIBING OFFICER/AUTHORITY SIGNATURE

ACCOUNT NUMBER

SSN

PHONE

ADDRESS CONTINUED

CITY, STATE, ZIP

RES RET MC OTHER*

EYE BRIDGE TEMPLE COLOR

DIST

PD

NEAR LENS TINT MATERIAL PAIR CASE

V PRISM V BASE

LAB USE

PRIORITY TECH INITIALS

DISTRIBUTION: ORIGINAL - Retained by Lab. COPY 1 - Returned with eyewear. COPY 2 - Entered in health record.

DD FORM 771, JUL 96 PREVIOUS EDITION IS OBSOLETE.

brian.d.miller2 Typewritten Text Attachment II – DD771