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www.northtorontoeyecare.com Fax: (416) 748-8582 | Phone: (416) 748-2020 | Email: [email protected] Ocular  GTA NW (Main Office) 2065 Finch Ave West, Suite #400 M3N 1W8 Physicians &  Central GTA (Surgical Center) 2 Champagne Drive, Unit C2 M3J 2C5 Surgeons  North York 7 Elmwood Ave M2N 6R6 PLEASE CIRCLE: Please complete contact and patient information. URGENCY: □ Same Day □ ASAP □ Routine □ Follow Up T. Rabinovitch PLEASE INFORM PATIENT TO BRING CURRENT LIST OF MEDICATIONS, DROPS & PLEASE ADVISE PATIENT OF TWO POSSIBLE APPOINTMENTS (PRELIMINARY TESTING & DOCTOR EXAMINATION) Refractive Surgery & Uveitis Last Name: ______First Name: ______DOB (Y/M/D): First Name: ______Phone #: ______Address:_ J. Waisberg OHIP: _ Version Code:Version Ophthalmology Referring Doctor:  Dr. Dry Eye Disease Cosmetic Botox Address: Postal Code: T Fax: Tel:

______REFRACTIVE

SURGERY

M. Azadeh GLAUCOMA  High IOP  Lasik/PRK Consult CATARACTS  PRIVATE  OHIP Cataract Surgery Ophthalmology  Disc Cupping  RLE/CLE  Premium Lens  VF Field Loss  ICL  TRIFOCAL/EDOF

 Narrow Angles  FEMTO Cataract Surgery CORNEA  Keratoconus/CXL

 SLT/LPI N. Pesin ______ PCO (laser on site) (Performed on site)  Keratitis Cataract Surgery______OD OS OU Ophthalmology 

OCULOPLASTICS  AMD DRY WET  Pterygium  Chalazion/Lesions/Cyst  INFLAMMATORY  Hole/Tear/Detachment 

DISEASE

RETINA  Conjunctivitis T. Hess  ERM  Ocular Rosacea  Diabetic Retinopathy  Episcleritis/Scleritis Cataract Surgery  Ptosis  Macular Edema  Uveitis/Iritis

 Entropion/Ectropion  Choroidal Nevus  Cellulitis  Punctoplasty  Retinopexy/Focal/Barrier 

TESTING

/PRP Laser (on site)  Visual Field/OCT BOTOX V. Lam  Blepharospasm Uveitis, Cataract &

DRY EYE DRY  MTO  Hemifacial Spasm Cornea Surgery  Tear Film Analysis  Pentacam Topography

 Hyperhidrosis  Lipiflow/IPL OD OS OU  Cosmetic/Fillers  Tearing/Blocked Duct

T. Le OD OS Cataract Surgery Ophthalmology BCVA Paediatric IOP REFRACTION

G. Yau Additional Information: Medical Retina Cataract Surgery

NO PREFERENCE

For EMERGENCIES please contact 416-748-7116 or 416-748-2020 ext. 0

Please feel free to fill out a referral form on our website at www.northtorontoeyecare.com

Please direct your patients to our patient education videos available on our website