Bifocal Plastic SV Near SPH CYL AXIS PRISM Frame: Trifocal Plastic Metal RIGHT Item Numbers LEFT Condition treated (WHITE CARD holders only): Reason for replacement (if within two years): ADD + Significant refraction change Broken* Lost* *written declaration attached PRESCRIBER I certify that the above prescription has been prescribed in accordance with DISPENSER I certify that the above described spectacles have been dispensed in SIGNATURE Department of Veterans’ Affairs requirements. SIGNATURE accordance with Department of Veterans’ Affairs requirements. Medicare/DVA Provider Number Medicare/DVA Provider Number
D931 (03/10) – Original – Department copy
Save Print Clear cut on this line Australian Government Department of Veterans’Affairs P VM95627 A PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT TO SIGN T I FULL Spectacles Prescription E NAME N T DATE OF BIRTH Date patient assessed: D ADDRESS Specifications: E T A I L S File number Lens: Glass SV Distance Bifocal Plastic SV Near SPH CYL AXIS PRISM Frame: Trifocal Plastic Metal RIGHT Item Numbers LEFT Condition treated (WHITE CARD holders only): Reason for replacement (if within two years): ADD + Significant refraction change Broken* Lost* *written declaration attached PRESCRIBER I certify that the above prescription has been prescribed in accordance with DISPENSER I certify that the above described spectacles have been dispensed in SIGNATURE Department of Veterans’ Affairs requirements. SIGNATURE accordance with Department of Veterans’ Affairs requirements. Medicare/DVA Provider Number Medicare/DVA Provider Number
D931 (03/10) – Duplicate – Dispenser copy
cut on this line
Australian Government Department of Veterans’Affairs P VM95627 A PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT TO SIGN T I FULL Spectacles Prescription E NAME N T DATE OF BIRTH Date patient assessed: D ADDRESS Specifications: E T A I L S File number Lens: Glass SV Distance Bifocal Plastic SV Near SPH CYL AXIS PRISM Frame: Trifocal Plastic Metal RIGHT Item Numbers LEFT Condition treated (WHITE CARD holders only): Reason for replacement (if within two years): ADD + Significant refraction change Broken* Lost* *written declaration attached PRESCRIBER I certify that the above prescription has been prescribed in accordance with DISPENSER I certify that the above described spectacles have been dispensed in SIGNATURE Department of Veterans’ Affairs requirements. SIGNATURE accordance with Department of Veterans’ Affairs requirements. Medicare/DVA Provider Number Medicare/DVA Provider Number