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  • Eyewear Prescription: Prescribed by Dodi 6040.35

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    Awais A.
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    This document is an eyewear prescription form containing fields to provide patient and prescribing officer information as well as details of the prescription including sphere, cylinder, axis, lens type, tint, and other specifications. It directs the lab to return a copy with the completed eyewear and enter a copy in the patient's health record.

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    dd0771.pdf

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    This document is an eyewear prescription form containing fields to provide patient and prescribing officer information as well as details of the prescription including sphere, cylinder, axis, lens type, tint, and other specifications. It directs the lab to return a copy with the completed eyewear and enter a copy in the patient's health record.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    26 views1 page

    Eyewear Prescription: Prescribed by Dodi 6040.35

    Uploaded by

    Awais A.
    This document is an eyewear prescription form containing fields to provide patient and prescribing officer information as well as details of the prescription including sphere, cylinder, axis, lens type, tint, and other specifications. It directs the lab to return a copy with the completed eyewear and enter a copy in the patient's health record.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    (THIS FORM IS SUBJECT TO THE

    PRIVACY ACT OF 1974 -

    Prescribed by DoDI 6040.35 Use DD Form 2005.)

    EYEWEAR DATE ACCOUNT NUMBER ORDER NUMBER


    PRESCRIPTION
    TO: (Lab) FROM:

    NAME (Last, First) SSN GRADE

    ADDRESS/UNIT PHONE

    ADDRESS CONTINUED SHIP TO:

    CLINIC PATIENT
    CITY, STATE, ZIP

    AD RES NG RET OTHER* A N AF MC CG PHS OTHER*

    FRAME EYE BRIDGE TEMPLE COLOR

    DIST NEAR LENS TINT MATERIAL PAIR CASE


    PD

    SPHERE CYLINDER AXIS DECENTER H PRISM H BASE V PRISM V BASE

    MULTIVISION LAB USE

    NEAR ADD SEG HT TOTAL DECENTER

    PRIORITY TECH INITIALS


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

    PRESCRIBING OFFICER/AUTHORITY SIGNATURE

    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.


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