diseases and surgery of the retina and vitreous...
TRANSCRIPT
A. Samuel Barloon, MDCharles Birnbach, MDYicheng Chen, M.D.Robert Francis, MDSteve H. Kim, MDTodd Klesert, MD, PhDCindy W. Mi, M.D.Robert Nash, MDDavid Saperstein, MDCraig Wells, MD
Diseases and Surgery of the Retina and Vitreous Specialists
Retinal Consultation Request Date ___________________________
Referring Doctor ___________________________________________________________
Patient Name_________________________________ Date of Birth _________________
Patient Phone Number _____________________________________________________
Vision OD ____________________________OS _______________________________
Suspected problem or symptoms ____________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
BELLEVUE 1750 112th Ave NE Suite D050, Bellevue, WA 98004 BELLINGHAM 3105 Old Fairhaven Parkway Space #103, Bellingham, WA 98225 BURLINGTON 215 E George Hopper Rd, Burlington, WA 98233 ELLENSBURG 2205 W Dolarway Road Suite 2, Ellensburg WA 98926 KENT 321 Ramsay Way, Suite 107, Kent, WA 98032 MOUNTLAKE TERRACE 6100 219th St SW, Suite 280, Mountlake Terrace, WA 98043 SEATTLE 1229 Madison Street Suite 620, Seattle, WA 98104
OD OS
Bellevue Bellingham
Burlington
NORTH
Bellevu
e Way N
E
NE 24th St
116th A
ve NE
NE 12th St
NE 10th St
NE 8th St
112th A
ve NE
Hidden Valley Sports Park
520
E&W 520 Exit ontoI-405 S
405
OverlakeHospitalMedicalCenter
N&S I-405Exit 8th St
Pike St
NORTH
I-90
VirginiaMason
HospitalSwedish MedicalCenter
HarborviewMedicalCenter
SeattleUniversity
Bro
adw
ay
Pike St
Union St
University St
Seneca St
Spring St
7th Ave
Boren Ave
S I-5Exit 165A
I-5
NORTH
I-5
Exit 229
HamptonInn &Suites
Cascade Mall
Shopping Center
Pease Road
S B
urlin
gto
n B
lvdO
ld H
wy 99 S
E George Hopper R
d
NORTH
219th St SW
64th
Ave
W
222nd St SW
60th
Ave
W
MountlakeTerrace City Hall
I-5
I-5
220th St SW
N I-5Exit 179
S I-5Exit 179
Madison StJames St
N I-5Exit 164A
NORTH
Bellevu
e Way N
E
NE 24th St
116th A
ve NE
NE 12th St
NE 10th St
NE 8th St
112th A
ve NE
Hidden Valley Sports Park
520
E&W 520 Exit ontoI-405 S
405
OverlakeHospitalMedicalCenter
N&S I-405Exit 8th St
Pike St
NORTH
I-90
VirginiaMason
HospitalSwedish MedicalCenter
HarborviewMedicalCenter
SeattleUniversity
Bro
adw
ay
Pike St
Union St
University St
Seneca St
Spring St
7th Ave
Boren Ave
S I-5Exit 165A
I-5
NORTH
I-5
Exit 229
HamptonInn &Suites
Cascade Mall
Shopping Center
Pease Road
S B
urlin
gto
n B
lvdO
ld H
wy 99 S
E George Hopper R
d
NORTH
219th St SW
64th
Ave
W
222nd St SW
60th
Ave
W
MountlakeTerrace City Hall
I-5
I-5
220th St SW
N I-5Exit 179
S I-5Exit 179
Madison StJames St
N I-5Exit 164A
Mountlake Terrace
NORTH
Bellevu
e Way N
E
NE 24th St
116th A
ve NE
NE 12th St
NE 10th St
NE 8th St
112th A
ve NE
Hidden Valley Sports Park
520
E&W 520 Exit ontoI-405 S
405
OverlakeHospitalMedicalCenter
N&S I-405Exit 8th St
Pike St
NORTH
I-90
VirginiaMason
HospitalSwedish MedicalCenter
HarborviewMedicalCenter
SeattleUniversity
Bro
adw
ay
Pike St
Union St
University St
Seneca St
Spring St
7th Ave
Boren Ave
S I-5Exit 165A
I-5
NORTH
I-5
Exit 229
HamptonInn &Suites
Cascade Mall
Shopping Center
Pease Road
S B
urlin
gto
n B
lvdO
ld H
wy 99 S
E George Hopper R
d
NORTH
219th St SW
64th
Ave
W
222nd St SW
60th
Ave
W
MountlakeTerrace City Hall
I-5
I-5
220th St SW
N I-5Exit 179
S I-5Exit 179
Madison StJames St
N I-5Exit 164A
Seattle
NORTH
Bellevu
e Way N
E
NE 24th St
116th A
ve NE
NE 12th St
NE 10th St
NE 8th St
112th A
ve NE
Hidden Valley Sports Park
520
E&W 520 Exit ontoI-405 S
405
OverlakeHospitalMedicalCenter
N&S I-405Exit 8th St
Pike St
NORTH
I-90
VirginiaMason
HospitalSwedish MedicalCenter
HarborviewMedicalCenter
SeattleUniversity
Bro
adw
ay
Pike St
Union St
University St
Seneca St
Spring St
7th Ave
Boren Ave
S I-5Exit 165A
I-5
NORTH
I-5
Exit 229
HamptonInn &Suites
Cascade Mall
Shopping Center
Pease Road
S B
urlin
gto
n B
lvdO
ld H
wy 99 S
E George Hopper R
d
NORTH
219th St SW
64th
Ave
W
222nd St SW
60th
Ave
W
MountlakeTerrace City Hall
I-5
I-5
220th St SW
N I-5Exit 179
S I-5Exit 179
Madison StJames St
N I-5Exit 164A
NORTH
Bellevu
e Way N
E
NE 24th St
116th A
ve NE
NE 12th St
NE 10th St
NE 8th St
112th A
ve NE
Hidden Valley Sports Park
520
E&W 520 Exit ontoI-405 S
405
OverlakeHospitalMedicalCenter
N&S I-405Exit 8th St
Pike St
NORTH
I-90
VirginiaMason
HospitalSwedish MedicalCenter
HarborviewMedicalCenter
SeattleUniversity
Bro
adw
ay
Pike St
Union St
University St
Seneca St
Spring St
N I-5Exit 164A
7th Ave
Boren Ave
S I-5Exit 165A
I-5
NORTH
I-5
Exit 229
HamptonInn &Suites
Cascade Mall
Shopping Center
Pease Road
S B
urlin
gto
n B
lvdO
ld H
wy 99 S
E George Hopper R
d
NORTH
219th St SW
64th
Ave
W
222nd St SW
60th
Ave
W
MountlakeTerrace City Hall
I-5
I-5
220th St SW
N I-5Exit 179
S I-5Exit 179
Madison StJames St
Kent Station
W James St
W Smith St
W Willis St E Willis St
2nd
Ave
S2n
d A
ve N
Cen
tral Ave S
516
S 167Exit WA-516
4th
Ave
S
1st
Ave
N
Ramsay Way
N 167Exit WA-516
167
167
KentEllensburg
NORTH
I90
Exit 106
W University Way
I90
N D
olarway
W Dolarway RD
97
I-5
I-5
Old Fairhaven Pkwy
Connelly Ave250
250
30th
Str
eet
N&S I5 Exit onto
250NORTH