PDF Map and Referral Form for PDF Map and Referral Form for

Retina-Vitreous Associates Medical Group
TO: , David S. Boyer, M.D., Inc.
, Thomas G. Chu, M.D., Ph.D., Inc.
, Homayoun Tabandeh, M.D., M.S., F.R.C.P., F.R.C.Ophth
, Pouya N. Dayani, M.D., Inc.
, Alexander C. Walsh, M.D.
,
,
,
,
,
Roger L. Novack, M.D., Ph.D., F.A.C.S., Inc.
Firas M. Rahhal, M.D., Inc.
Richard H. Roe, M.D., M.H.S., Inc.
David S. Liao, M.D., Ph.D.
Daniel D. Esmaili, M.D.
Patient Name ________________________________Date of Birth_____/_____/_____Appointment Date/Time____/____/____ ___________
Please send this form, along with the patient’s chart notes or a letter, in advance of the patient’s scheduled appointment or ask the patient to bring
this information on the day of the appointment.
Referring Physician ___________________________________Phone_________________Fax_________________E-mail_________________
Address_____________________________________________________________________________________________________________
I am sending this patient to you for assistance with his/her care. Please evaluate this patient’s problem(s) or condition(s) (pls. describe)
___________________________________________________________________________________________________________________
and consider treatment, as appropriate. I look forward to receiving your opinion and advice regarding care of this patient and will resume
general care following your consultation.
,
,
,
,
Consultation with appropriate treatment
Consultation only
Fundus Photos
Fluorescein Angiography
,
,
,
,
B-Scan
Optical Coherence Tomography
Electrophysiologic testing
Other
Referring Physician’s Signature: ______________________________________________
Please call and send letter
Please send letter alone
Please FAX results A.S.A.P.
, Los Angeles Office
FROM THE 101 (HOLLYWOOD FREEWAY)
Take the 110 (Harbor Freeway) SOUTH. Follow
“Downtown” lanes to Wilshire Blvd. At Wilshire Blvd., turn
right (WEST) three blocks to Lucas Ave. Turn right on
Lucas Ave. for parking entrance.
FROM THE 110 (HARBOR FREEWAY)
Driving SOUTH -- (see Hollywood Freeway above).
Driving NORTH -- follow “Downtown” lanes to 9th Street exit.
Turn left on Figueroa, turn left on Wilshire, turn right on
Lucas Ave., right into parking.
FROM THE 10 (SANTA MONICA FREEWAY)
Take the 110 NORTH (Harbor Freeway). Follow directions
for driving NORTH on the 110 (Harbor Freeway) above.
1127 Wilshire Blvd.
Suite 1620
Los Angeles, CA 90017
Telephone: (213) 483-8810
Fax: (213) 481-1503
FROM WEST LOS ANGELES
Drive EAST on 3rd, 6th, or Wilshire Blvd. to Lucas Ave.
, Beverly Hills Office
FROM THE 10 (SANTA MONICA FREEWAY)
Exit at La Cienega Blvd. NORTH, follow La Cienega Blvd. to
Wilshire Blvd. Turn left onto Wilshire Blvd. (WEST). 9001
Wilshire Blvd. is on the right between Robertson Blvd. and
Doheny Dr. Parking is on N. Almont Dr.
FROM THE 405 (SAN DIEGO FREEWAY)
Exit Wilshire Blvd EAST. Follow Wilshire Blvd. EAST.
FROM PALOS VERDES, MANHATTAN BEACH
Take the 405 NORTH (San Diego Freeway) and follow
directions above.
FROM DOWNTOWN LOS ANGELES
Take the 10 WEST (Santa Monica Freeway) and follow
directions above.
9001 Wilshire Blvd.
Suite 301
Beverly Hills, CA 90211
Telephone: (310) 854-6201
Fax: (310) 652-7520
, North Hollywood Office
FROM PASADENA
Take 134 Fwy WEST (Ventura). Continue on to 101 Fwy
(Ventura). Exit on Coldwater Canyon. Turn right (NORTH) on
Coldwater Canyon. Turn right (EAST) on Riverside.
FROM SIMI VALLEY
Take 118 Fwy (SOUTH) to the 405 Fwy. Take 405 Fwy (SOUTH) to
the 101 Fwy. Take 101 (SOUTH), exit Coldwater Canyon. Turn left
(NORTH) on Coldwater Canyon. Turn right (EAST) on Riverside.
FROM THOUSAND OAKS
Take 101 Fwy (SOUTH) to Los Angeles. Exit on Coldwater
Canyon (NORTH). Turn left (NORTH) on Coldwater Canyon. Turn
right (EAST) on Riverside.
12840 Riverside Dr.
Suite 333
North Hollywood, CA 91607
Telephone: (818) 754-2090
Fax: (818) 508-9420
FROM WEST LOS ANGELES
Take 405 Fwy (NORTH) to the 101 Fwy. Take 101 Fwy (SOUTH)
to Los Angeles. Exit on Coldwater Canyon. Turn left (NORTH) on
Coldwater Canyon. Turn right (EAST) on Riverside.
www.laretina.com
, Torrance Office
FROM THE 405 (SAN DIEGO FREEWAY)
(From 405 NORTH) Take Crenshaw off-ramp, turn left, go
approximately 5 miles SOUTH on Crenshaw Blvd. to Lomita Blvd.
At Lomita Blvd., turn right (WEST) for approximately 1 mile to
office. (Office is located on left, across from Torrance Hospital).
(From 405 SOUTH) Take Crenshaw off-ramp, turn right, go
approximately 5 miles SOUTH on Crenshaw Blvd. to Lomita Blvd.
At Lomita Blvd., turn right (WEST) for approximately 1 mile to
office. (Office is located on left, across from Torrance Hospital).
3440 Lomita Blvd.
Suite 327
Torrance CA 90505
Telephone: (310) 891-1000
Fax: (310) 891-1003
FROM THE 110 (HARBOR FREEWAY)
(From 110 NORTH) Take Sepulveda off-ramp, turn left, go 7 miles
WEST to Crenshaw Blvd, turn left on to Crenshaw Blvd. At Lomita
Blvd., turn right (WEST) for approximately 1 mile to office.
(Office is located on left, across from Torrance Hospital).
(From 110 SOUTH) Take Sepulveda off-ramp, turn right, go 7
miles WEST to Crenshaw Blvd., turn left on to Crenshaw Blvd. At
Lomita Blvd., turn right (WEST) for approximately 1 mile to
office. (Office is located on left, across from Torrance Hospital).
FROM THE 91 (ARTESIA FREEWAY)
Exit onto 110 Fwy (Harbor Fwy) SOUTH (San Pedro) and follow
the 110 (HARBOR FREEWAY) directions.
, Santa Clarita Office
FROM LANCASTER / PALMDALE
Take the 14 Fwy (Antelope Valley) SOUTH to Soledad
Canyon Rd. Soledad Canyon Rd. becomes Valencia Blvd. after
the Bouquet Canyon intersection. Continue on Valencia Blvd.
to Cinema Dr., and turn left.
FROM THE 5 (GOLDEN STATE FWY)
(From NORTH - Castaic) Take Valencia Blvd. off-ramp, turn left
(EAST) to Cinema Dr., turn right on Cinema Dr.
(From SOUTH) Take Valencia Blvd. off-ramp, turn right (EAST)
to Cinema Dr., turn right on Cinema Dr.
23501 Cinema Dr.
Suite 109
Santa Clarita, CA 91355
Telephone: (661) 290-2336
Fax: (661) 290-2346
, Pasadena Office
FROM 210 FREEWAY
Take the Fair Oaks/Marengo exit. Go SOUTH on
Fair Oaks Ave. Cross street is Del Mar Blvd. Parking is
off Del Mar on south side of the street
FROM THE 110 FREEWAY
Take the Fair Oaks exit. Go NORTH on Fair Oaks Ave.
Cross Street is Del Mar Blvd. Parking is off Del Mar on
south side of the street.
301 S. Fair Oaks Ave.
Suite 301
Pasadena, CA 91105
Telephone: (626) 204-1410
Fax: (626) 204-1420
, Tarzana Office
FROM 101 FREEWAY
Take the Reseda South exit. Turn Left on
Clark Street. Turn Left on Etiwanda. Parking is
left side of the street.
5525 Etiwanda Ave.
Suite 112
Tarzana, CA 91356
Telephone: (818) 578-7408
Fax: (818) 578-7409
www.laretina.com