Retinal Diagnostic Center

Retinal Diagnostic Center
Your appointment has been made for retinal evaluation on
____________________________ at ________ o’clock.
Brian Ward, Ph.D., M.D.
Howard H. Chen. M.D.
To avoid multiple visits, facilities are available for any necessary
testing. This means that you should allow up to 2 hours for the
visit, although your time in the office could be much less.
Your pupils will be dilated, however, there is usually no discomfort
associated with testing.
Clement Chow, M.D.
Retinal Referral Form
Patient’s Name
Address
We look forward to your visit.
Patrick Monahan, M.D.
Amr L. Dessouki, M.D.
______________________________________
__________________________________________________
Phone________________________ ____________________________
(Home)
(Work)
Diagnosis: ______________________________________________________
Visual Acuity:
EL CAMINO REA
L
880
101
680
.
A
GRANT
ve.
sA
AV
E.
SC
OM
AVE
NUE
ON
CKS
KS
.
AVE
res
gue
e Fi
87
Jos
RETINAL
DIAG. CTR.
Los Gatos/
San Jose WHIT
Other Information
REGIONAL
MEDICAL
CENTER OF
SAN JOSE
KEE
Mc
. JA
NO
BA
DEN
E OA
KA
VE.
OCK
MR
ALU
REGIONAL
MEDICAL
CENTER OF
SAN JOSE
CAM
LAR
OS
Mc
ere
nue
Ave
17
OD
KEE
RD
igu
280
85
Fundus Area of interest
RETINAL
DIAGNOSTIC
CENTER
San Jose
eF
EL CAMINO
HOSPITAL
L.E. 20/
Jos
ROAD
SS
YE
RR
BE
R.E. 20/
M
ALU
CK
RO
680
Referring Doctor ______________________________________ Date ______
(408) 937-0928 FAX (408) 254-8954
200 Jose Figueres Avenue, Suite 240, San Jose, CA 95116
www.retinaldiagnostic.com