Form for Optician / Optometrist
 

Some time ago, my (then) medical examiner gave me a form headed 'To the Optician/Optometrist' and sent me off to get an eye test. Some years later, I think I am going to need a new prescription, and would like to have another copy of the form to show the optician.
The one I had before was overprinted with the examiner's personal details, but I believe it was originally a CAA form that he had fancied up. I would really like to present an anonymised version to my optician, but I can't find it on the CAA website. I attach a scan of the 'meat' of the form.
Two questions I would welcome advice on: is it still a valid CAA form, and - if it is - where can I find it?

In 20+ years of flying I have only ever taken my latest eye test/prescription for a medical. Never been asked to take/supply a form.

Lucky you!