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form dd 771
form dd 771

Fillable DD Form 771, Eyewear Prescription, July 1996 - DTIC - dtic

Description

PRESCRIBING OFFICER/AUTHORITY DISTRIBUTION SIGNATURE ORIGINAL - Retained by Lab. DD FORM 771 JUL 96 COPY 1 - Returned with eyewear. THIS FORM IS SUBJECT TO THE PRIVACY ACT OF 1974 - Use DD Form 2005. EYEWEAR PRESCRIPTION ACCOUNT NUMBER DATE TO Lab ORDER NUMBER FROM NAME Last First SSN GRADE ADDRESS/UNIT PHONE ADDRESS CONTINUED SHIP TO CLINIC PATIENT CITY STATE ZIP AD RES NG FRAME PD RET OTHER A N AF MC CG EYE DIST...
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