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Spectacles Prescription

Date patient assessed:


Specifications:

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) – Original – Department copy


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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

D931 (03/10) – Triplicate – Prescriber copy