Form DD 771 PDF Details

This page provides information about Form DD 771. There, you'll obtain the details about the form you intend to fill in, such as the estimated time for you to complete it and also other details.

QuestionAnswer
Form Name Form Dd 771
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names form 771, dd 771 pdf, 771 subject 1996, formdd771

Form Preview Example

Prescribed by DoDI 6040.35

(THIS FORM IS SUBJECT TO THE

PRIVACY ACT OF 1974 -

Use DD Form 2005.)

EYEWEAR

PRESCRIPTION

DATE

ACCOUNT NUMBER

ORDER NUMBER

TO: (Lab)

FROM:

NAME (Last, First)

ADDRESS/UNIT

ADDRESS CONTINUED

CITY, STATE, ZIP

SSN

GRADE

 

PHONE

 

 

 

 

 

 

 

 

 

 

SHIP TO:

 

 

 

 

CLINIC

 

PATIENT

 

 

 

 

 

 

 

 

AD

RES

NG

RET

OTHER*

A

N

AF

MC

CG

PHS

OTHER*

FRAME

 

EYE

 

BRIDGE

 

TEMPLE

 

COLOR

 

 

PD

DIST

NEAR

LENS

 

TINT

 

MATERIAL

 

PAIR

CASE

 

 

 

 

 

 

 

 

 

 

 

 

SPHERE

CYLINDER

AXIS

DECENTER

 

H PRISM

H BASE

V PRISM

V BASE

R

L

MULTIVISION

NEAR ADD

SEG HT

TOTAL DECENTER

R

L

LAB USE

 

 

PRIORITY

TECH INITIALS

 

 

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PREVIOUS EDITION IS OBSOLETE.

Reset

How to Edit Form DD 771 Online for Free

Completing form dd 771 is easy. Our team created our software to make it user-friendly and uncomplicated and enable you to complete any form online. Listed here are steps you need to follow:

Step 1: Hit the button "Get form here" to access it.

Step 2: Now you are on the form editing page. You may enhance and add text to the form, highlight words and phrases, cross or check selected words, add images, insert a signature on it, erase needless fields, or eliminate them completely.

Create the particular parts to prepare the template:

portion of empty spaces in dd 771

You have to provide the appropriate details in the PRESCRIBING OFFICERAUTHORITY, SIGNATURE, DISTRIBUTION, ORIGINAL Retained by Lab, COPY Returned with eyewear, COPY Entered in health record, DD FORM JUL, and PREVIOUS EDITION IS OBSOLETE area.

stage 2 to finishing dd 771

Step 3: After you have selected the Done button, your document should be available for upload to every gadget or email address you indicate.

Step 4: Ensure you keep away from possible future challenges by generating at least a pair of copies of the form.

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