DA Form 3365 Authorization for Medical Warning Tag

DA Form 3365 - also known as the "Authorization For Medical Warning Tag" - is a Military form issued and used by the United States Department of the Army.

The form - often mistakenly referred to as the DD form 3365 - was last revised on August 1, 1968. Download an up-to-date fillable PDF version of the DA 3365 below or request a copy through the chain of command.

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AUTHORIZATION FOR MEDICAL WARNING TAG
For use of this form, see AR 40-66; the proponent agency is Office of The Surgeon General.
TO:
FROM:
(Include ZIP Code)
(Medical Treatment Facility (Specify Clinic, Ward, etc.))
TYPED NAME AND SIGNATURE OF REQUESTING MEDICAL OR DENTAL OFFICER
DATE
TAG CONTENT
SPACE NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
1
2
3
4
5
REMARKS
TAG DELIVERED TO PATIENT (Signature of Responsible Officer)
DATE DELIVERED
PERSON TO CALL IF OTHER THAN PATIENT
NAME AND RELATIONSHIP TO PATIENT
ADDRESS
PHONE NUMBER
PATIENT IDENTIFICATION
ORGANIZATION, UNIT, LOCATION (Military Pers ONLY)
HOME ADDRESS (Include Zip Code)
PHONE NUMBER
PATIENT'S NAME (Last, first, middle)
GRADE OR STATUS
IDENTIFICATION NUMBER
DA FORM 3365, AUG 1968
APD LC v1.02ES
AUTHORIZATION FOR MEDICAL WARNING TAG
For use of this form, see AR 40-66; the proponent agency is Office of The Surgeon General.
TO:
FROM:
(Include ZIP Code)
(Medical Treatment Facility (Specify Clinic, Ward, etc.))
TYPED NAME AND SIGNATURE OF REQUESTING MEDICAL OR DENTAL OFFICER
DATE
TAG CONTENT
SPACE NUMBER
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
1
2
3
4
5
REMARKS
TAG DELIVERED TO PATIENT (Signature of Responsible Officer)
DATE DELIVERED
PERSON TO CALL IF OTHER THAN PATIENT
NAME AND RELATIONSHIP TO PATIENT
ADDRESS
PHONE NUMBER
PATIENT IDENTIFICATION
ORGANIZATION, UNIT, LOCATION (Military Pers ONLY)
HOME ADDRESS (Include Zip Code)
PHONE NUMBER
PATIENT'S NAME (Last, first, middle)
GRADE OR STATUS
IDENTIFICATION NUMBER
DA FORM 3365, AUG 1968
APD LC v1.02ES

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