Los Angeles Office

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Re tina-Vitreous A ssociates M edical G roup TO: , David S. Boyer, M.D., Inc. , Roger L. Novack, M.D., Ph.D., F.A.C.S., Inc. , Thomas G. Chu, M.D., Ph.D., Inc. , Firas M. Rahhal, M.D., Inc. , Homayoun Tabandeh, M.D., M.S., F.R.C.P., F.R.C.Ophth , Richard H. Roe, M.D., M.H.S., Inc. , Pouya N. Dayani, M.D., Inc. , David S. Liao, M.D., Ph.D., Inc. , Daniel D. Esmaili, M.D. , Jeffrey J. Tan, M.D. , Alexander C. Walsh, 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 , B-Scan , Consultation only , Optical Coherence Tomography , Fundus Photos , Electrophysiologic testing , Fluorescein Angiography , Other Please call and send letter Please send letter alone Referring Physician’s Signature: ______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 ) four blocks to Witmer St. Turn left on Shatto St. 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 on Witmer St., left on Shatto St., to parking entrance on the right. FROM THE 10 (SANTA MONICA FREEWAY) 1245 Wilshire Blvd. Take the 110 NORTH (Harbor Freeway). Follow directions Suite 380, South Tower for driving NORTH on the 110 (Harbor Freeway) above. Los Angeles, CA 90017 FROM WEST LOS ANGELES Telephone: (213) 483-8810 Drive EAST on 3rd, 6th, or Wilshire Blvd. Turn left to Witmer St., Fax: (213) 481-1503 turn left on Shatto St., to parking entrance on the right.

, 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

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, 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 FROM WEST LOS ANGELES North Hollywood, CA 91607 Take 405 Fwy ( NORTH ) to the 101 Fwy. Take 101 Fwy ( SOUTH ) Telephone: (818) 754-2090 to Los Angeles. Exit on Coldwater Canyon. Turn left ( NORTH ) on Fax: (818) 508-9420 Coldwater Canyon. Turn right ( EAST ) on Riverside.

, 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).

3400 Lomita Blvd. FROM THE 110 (HARBOR FREEWAY) Suite 202 (From 110 NORTH ) Take Sepulveda off-ramp, turn right, go 7 Torrance CA 90505 miles WEST to Crenshaw Blvd, turn left on to Crenshaw Blvd. At Telephone: (310) 891-1000 Lomita Blvd., turn right ( WEST ) for approxi mately 1 mile to Fax: (310) 891-1003 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.

, 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 407 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