DD Form 771 Eyewear Prescription

What Is DD Form 771?

DD Form 771, Eyewear Prescription is a form used for ordering prescription eyewear. The majority of orders are made via the Department of Defense (DoD) Spectacle Request Transmission System (SRTS) that provides a ready-made DD 771 when an order is printed out. If an area has no access to the SRTS the form may be completed and sent digitally or printed out and handed in to the servicing lab.

The DoD updated the form - sometimes incorrectly referred to as the DA Form 771 - in July 1996 with all previous editions being obsolete. An up-to-date DD Form 771 fillable version is available for digital filing and download below.

Both service members and retirees may use the DD 771. Retirees are eligible for annual eyewear orders. Those who have a TRICARE health plan and the required authorization may order eyewear through the Military Treatment Facility (MTF) or the Navy Ophthalmic Support Training Activity Command (NOSTRA) website if the nearest MTF is 50 miles away.

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(THIS FORM IS SUBJECT TO THE
PRIVACY ACT OF 1974 -
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
R
L
MULTIVISION
LAB USE
NEAR ADD
SEG HT
TOTAL DECENTER
R
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PREVIOUS EDITION IS OBSOLETE.
Reset
(THIS FORM IS SUBJECT TO THE
PRIVACY ACT OF 1974 -
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
R
L
MULTIVISION
LAB USE
NEAR ADD
SEG HT
TOTAL DECENTER
R
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.
Reset

Download DD Form 771 Eyewear Prescription

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How to Fill out DD Form 771?

No filling guidelines are distributed with the form by the DoD. DD Form 771 instructions are as follows.

  1. The date of filing - along with the account number and order number - are specified in the corresponding sections at the top of the page. The laboratory address and the sender's information should be placed in Sections labeled "To" and "From";
  2. The form continues with self-explanatory sections specifying the patient's data (their name, SNN, grade, address, and phone number). No Army or Field Post Office addresses may be given. It is also necessary to identify the recipient of the order. Orders can be received by the clinic or by the patient;
  3. The further sections identify the parameters of the ordered eyewear and are completed according to the patient's needs. The minimum information to be filled in includes pupillary distances, axis (when the cylinder box is provided) and segment height for bifocals;
  4. The "Special Comments" section is for clarifying the information if the sections titled "Other" are filled in;
  5. The prescribing officer or authority inserts their name and signature at the bottom of the page. A copy of the form will be brought with the completed order and another copy wil be kept with the patient's health record.