DA Form 3365 "Authorization for Medical Warning Tag"

What Is DA Form 3365?

This is a military form that was released by the U.S. Department of the Army (DA) on August 1, 1968. The form, often mistakenly referred to as the DD Form 3365, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 3365 down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 3365 "Authorization for Medical Warning Tag"

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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