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.

, Daniel D. Esmaili, M.D.

, Alexander C. Walsh, M.D.

, Consultation with appropriate treatment

, Consultation only

, Fundus Photos

, Fluorescein Angiography

, B-Scan

, Optical Coherence Tomography

, Electrophysiologic testing

, OtherPlease call and send letter

Please send letter alone

Please FAX results A.S.A.P.

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 bringthis 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 resumegeneral care following your consultation.

Referring Physician’s Signature: ______________________________________________

, Los Angeles Office

, Beverly Hills Office

, 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., Inc.

, Jeffrey J. Tan, M.D.

FROM THE 10 (SANTA MONICA FREEWAY)Exit at La Cienega Blvd. NORTH, follow La Cienega Blvd. toWilshire Blvd. Turn left onto Wilshire Blvd. (WEST). 9001Wilshire Blvd. is on the right between Robertson Blvd. andDoheny 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 BEACHTake the 405 NORTH (San Diego Freeway) and followdirections above.

FROM DOWNTOWN LOS ANGELESTake the 10 WEST (Santa Monica Freeway) and followdirections above.

9001 Wilshire Blvd.Suite 301

Beverly Hills, CA 90211Telephone: (310) 854-6201

Fax: (310) 652-7520

www.laretina.com

FROM THE 101 (HOLLYWOOD FREEWAY)Take the 110 (Harbor Freeway) SOUTH. Follow“Downtown” lanes to Wilshire Blvd. At Wilshire Blvd., turnright (WEST) four blocks to Witmer St. Turn left on ShattoSt. for parking entrance on the right.

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 onWitmer St., left on Shatto St., to parking entrance on theright.

FROM THE 10 (SANTA MONICA FREEWAY)Take the 110 NORTH (Harbor Freeway). Follow directionsfor driving NORTH on the 110 (Harbor Freeway) above.

FROM WEST LOS ANGELESDrive EAST on 3rd, 6th, or Wilshire Blvd. Turn left to Witmer St.,turn left on Shatto St., to parking entrance on the right.

1245 Wilshire Blvd.Suite 380, South TowerLos Angeles, CA 90017

Telephone: (213) 483-8810Fax: (213) 481-1503

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FROM THE 405 (SAN DIEGO FREEWAY)(From 405 NORTH) Take Crenshaw off-ramp, turn left, goapproximately 5 miles SOUTH on Crenshaw Blvd. to Lomita Blvd.At Lomita Blvd., turn right (WEST) for approximately 1 mile tooffice. (Office is located on left, across from Torrance Hospital).

(From 405 SOUTH) Take Crenshaw off-ramp, turn right, goapproximately 5 miles SOUTH on Crenshaw Blvd. to Lomita Blvd.At Lomita Blvd., turn right (WEST) for approximately 1 mile tooffice. (Office is located on left, across from Torrance Hospital).

FROM THE 110 (HARBOR FREEWAY)(From 110 NORTH) Take Sepulveda off-ramp, turn right, go 7miles WEST to Crenshaw Blvd, turn left on to Crenshaw Blvd. AtLomita Blvd., turn right (WEST) for approxi mately 1 mile tooffice. (Office is located on left, across from Torrance Hospital).

(From 110 SOUTH) Take Sepulveda off-ramp, turn right, go 7miles WEST to Crenshaw Blvd., turn left on to Crenshaw Blvd. AtLomita Blvd., turn right (WEST) for approximately 1 mile tooffice. (Office is located on left, across from Torrance Hospital).

FROM THE 91 (ARTESIA FREEWAY)Exit onto 110 Fwy (Harbor Fwy) SOUTH (San Pedro) and followthe 110 (HARBOR FREEWAY) directions.

FROM 210 FREEWAYTake 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 FREEWAYTake the Fair Oaks exit. Go NORTH on Fair Oaks Ave.Cross Street is Del Mar Blvd. Parking is off Del Mar onsouth side of the street.

, Torrance Office

3400 Lomita Blvd.Suite 202

Torrance CA 90505Telephone: (310) 891-1000

Fax: (310) 891-1003

, Pasadena Office

301 S. Fair Oaks Ave.Suite 407

Pasadena, CA 91105Telephone: (626) 204-1410

Fax: (626) 204-1420

FROM 101 FREEWAYTake the Reseda South exit. Turn Left on Clark Street. Turn Left on Etiwanda. Parking is left side of the street.

, Tarzana Office

5525 Etiwanda Ave.Suite 112

Tarzana, CA 91356Telephone: (818) 578-7408

Fax: (818) 578-7409

www.laretina.com

, North Hollywood Office

12840 Riverside Dr.Suite 333

North Hollywood, CA 91607Telephone: (818) 754-2090

Fax: (818) 508-9420

FROM PASADENATake 134 Fwy WEST (Ventura). Continue on to 101 Fwy(Ventura). Exit on Coldwater Canyon. Turn right (NORTH) onColdwater Canyon. Turn right (EAST) on Riverside.

FROM SIMI VALLEYTake 118 Fwy (SOUTH) to the 405 Fwy. Take 405 Fwy (SOUTH) tothe 101 Fwy. Take 101 (SOUTH), exit Coldwater Canyon. Turn left(NORTH) on Coldwater Canyon. Turn right (EAST) on Riverside.

FROM THOUSAND OAKSTake 101 Fwy (SOUTH) to Los Angeles. Exit on ColdwaterCanyon (NORTH). Turn left (NORTH) on Coldwater Canyon. Turnright (EAST) on Riverside.

FROM WEST LOS ANGELESTake 405 Fwy (NORTH) to the 101 Fwy. Take 101 Fwy (SOUTH)to Los Angeles. Exit on Coldwater Canyon. Turn left (NORTH) onColdwater Canyon. Turn right (EAST) on Riverside.

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