patient referral form - seeclearly.com a. tagayun, m.d. john g. yassin, m.d. christine burris...

Diseases and Surgery of the Cornea Laser Vision Correction Laser Cataract Surgery / Premium IOLsCollagen Cross-LinkingSpecialty Contact Lens Fitting

Patient Name: ______________________________

Referring Doctor: ____________________________ Phone: _______________________

Reason for referral or diagnosis: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

See Clearly Vision GroupCornea Consultants8138 Watson StreetMcLean, VA 22102(703) 827-5454Fax: (703) 827-5539

5842 Hubbard DriveRockville, MD 20852(301) 770-6888Fax: (301) 770-5891

1715 N. George Mason DriveSuite 206Arlington, VA 22205(703) 525-4411Fax: (703) 525-0813

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Patient Referral Form Rajesh K. Rajpal, M.D.

Khoa D. Hoang, M.D.Christine A. Tagayun, M.D.

John G. Yassin, M.D.Christine Burris Wisecarver, O.D.

Sushil K. Jain, O.D.Dawn L. Williams, O.D.

A-scan/IOL Master BOTOX & Dermal Fillers Cataract Evaluation LenSx Laser Multifocal & Accomodating IOL Toric IOL Collagen Cross-Linking Contact Lens Fitting (Medical/Speciality/Scleral)

Contrast Sensitivity Corneal Cultures Corneal Evaluation Diabetes Evaluation Digital Photography Dry Eye Evaluation EyeXpress/BlephEx Foreign Body Removal Humphrey Visual Field Keratoconus Evaluation

Laser Vision Correction OCT Pachymetry Phakic IOL Punctal Plugs Raindrop Near Vision Inlay Specular Microscopy Tear Osmolarity TrueTear Topography

Thank you for your referral; a complete summary of the consultation will be sent to you.

Diseases and Surgery of the Cornea Laser Vision Correction Cataract Surgery

Patient Name: __________________________________________________________

Referring Doctor: ____________________________ Phone: ______________________

Reason for referral or diagnosis: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Procedure (if requested):





Walter Reed National Military Medical CenterDepartment of Ophthalmology8901 Wisconsin Ave, Building 8Bethesda, MD 20889

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Khoa D. Hoang, M.D.John G. Yassin, M.D.

Robert P. Friedlaender, M.D.Christine Burris Wisecarver, O.D.


A-scan/IOL Master Cataract Evaluation Collagen Cross-Linking Colvard Pupillometry Contrast Sensitivity Corneal Cultures Diabetes Evaluation

Digital Photography Foreign Body Removal GDx Nerve Fiber Analysis Humphrey Visual Field Intacs for Keratoconus Laser Vision Correction Multifocal and Toric IOL

Orbscan/Topography Pachymetry Pentacam Phakic IOL Punctal Plugs Specialty/Scleral CL Fitting Specular Microscopy

Diseases and Surgery of the Cornea Laser Vision Correction Cataract Surgery

Patient Name: __________________________________________________________

Referring Doctor: ____________________________ Phone: ______________________

Reason for referral or diagnosis: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Procedure (if requested):





Walter Reed National Military Medical CenterDepartment of Ophthalmology8901 Wisconsin Ave, Building 8Bethesda, MD 20889

**********************************


Khoa D. Hoang, M.D.John G. Yassin, M.D.

Robert P. Friedlaender, M.D.Christine Burris Wisecarver, O.D.


A-scan/IOL Master Cataract Evaluation Collagen Cross-Linking Colvard Pupillometry Contrast Sensitivity Corneal Cultures Diabetes Evaluation

Digital Photography Foreign Body Removal GDx Nerve Fiber Analysis Humphrey Visual Field Intacs for Keratoconus Laser Vision Correction Multifocal and Toric IOL

Orbscan/Topography Pachymetry Pentacam Phakic IOL Punctal Plugs Specialty/Scleral CL Fitting Specular Microscopy

Locations and Directions

Rockville Office

5842 Hubbard DriveRockville, MD 20852

From I-495From I-495N, merge onto I-270N.Take Montrose Road East, exit 4A.Turn left to continue on Montrose Road.Turn left onto East Jefferson Street.Turn right onto Rollins Avenue.Turn right onto Rockville Pike South, MD-355 South. Turn right onto Hubbard Drive. Make an immediate left into Georgetown Square Office Park.

Free parking is available in the office park or in the lower lot behind the 5842 building.

Tysons Corner Office

8138 Watson StreetMcLean, VA 22102

From the Beltway (I-495)Take exit 46A for VA-123 South/Chain Bridge Road/Tysons Corner/Vienna. Turn left onto International Drive.Turn right on Fletcher Street (Silver Diner will be on the corner).Fletcher Street becomes Watson Street. 8138 Watson Street is on the right. Free parking is available.

Arlington Office

1715 N. George Mason Dr., #206Arlington, VA 22205

From FairfaxTake I-66 East, and take the exitfor Glebe Road/Fairfax Drive.Make a left on Glebe Road, thenmake a left on N. 16th Street. Turnright on N. George Mason Drive. Our entrance is on the right side.

From Springfield/WoodbridgeTake I-395 N. Take the exit forN. Glebe Road. Then, make a lefton Washington Blvd. and a right on N. George Mason Drive. Ourentrance is on the right side.

Paid parking is available in parking garage C.

patient referral form - seeclearly.com a. tagayun, m.d. john g. yassin, m.d. christine burris...

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