2925 Lord Baltimore Drive, Suite 300 1600 Crain Highway, Suite 601 9106 Philadelphia Road, Suite 314Baltimore, MD 21244 Glen Burnie, MD 21061 Baltimore, MD 21237Fax (410) 281-9388 Fax (410) 590-1611 Fax (410) 391-0607PATIENT NAME DOB PATIENT REFERRED TO

DIAGNOSIS PATIENT PHONE NUMBER

APPOINTMENT DATE TIME ONSET DATEA.M.P. M.

i am sending this patient to you for assistance with his/her care. Please evaluate this patient’s problem(s) or condition(s):

q Blurred Vision q Entropion/Ectropion q Pterygium/Photoq Cataracts/IOL Master/MAP q Epiphora q Ptosis/Photosq Chalazion q Eye Pain/Redness q Refractive Surgery/ Lasik/PRKq Congenital Eye Disorder q Eyelid Lesions q Retinal Detachment/Tearq Conjunctivitis/Red Eye q Flashes/Floaters q Retinal Hemorrhageq Corneal Abrasion/Ulcer q Foreign Body q Retinal Vein Occlusion / OCTq Cosmetic q Glaucoma/Pach’s/NFL OCT/VF q Traumaq Dermatochalasis q Keratoconus/Corneal Map q Uveitis/Iritisq Diabetic Retinopathy/OCT q Macular Degeneration/OCT q Other:________________q Dry Eye/Osmolarity Test/RPS q Macular Disease/OCT

Results oF eXaMination

Refraction OD ________________________________________ BVA OD ________________________________________

OS ________________________________________ OS ________________________________________

IOP OD _______________mm Hg OS _______________mm Hg Time _______________am / pmCOMMENTS

ReFeRRinG PHYsiCian

Would You like to Co-ManaGe tHis Patient? TELEPHONE FAXq Yes q no

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.

REFERRING DOCTOR’S NAME (PLEASE PRINT)

REFERRING DOCTOR’S SIGNATURE DATE

Please send this form via fax in advance of the patient’s appointment and ask the patient to bring this form on the day of the

appointment. thank you.

OMNIEYE036 (Rev. 10/15)

omnieyespecialists.com

Consultation Request410-277-3937

2925 lord Baltimore drive, suite 300

Baltimore, Md 21244

traveling north on 695 Take exit 17 Security Blvd., toward Rolling Road.At the 3rd light, make a right onto Lord Baltimore Drive. Go approximately 2 miles; youwill pass 2 traffic lights. Just before the 3rd light (Windsor Mill Road), make a rightinto the parking lot of St. Luke’s Professional Center.traveling south on 695 Take exit 18 Randallstown/Liberty Road. Stay in the second lane from the right and continue straight across Liberty Rd. to Lord BaltimoreDrive. At the 1st light, make a left onto Windsor Mill Road, then an immediate rightinto the parking lot of St. Luke’s Professional Center.traveling from Columbia/ellicott CityTake Rt. 70 East to Rt. 695 North. Take exit 18B Randallstown/Liberty Road. **You must immediately get in the far left lane**At the 1st light, make a left onto Lord Baltimore Drive. Go approximately 1 mile. Make a left at the light onto Windsor Mill Road, then an immediate right into the parking lot of St. Luke’s Professional Center.

9106 Philadelphia Road, suite 314

Baltimore, Md 21237

traveling on i-695 Take exit 34 toward Rosedale. Turn left on Philadelphia Road, Rt. 7. Go approximately 1.3 miles. Immediately past Hospital Drive, turn left into the Seven Square Office Park. 9106 is the building on the left.traveling north on i-95 Exit I-695 East toward Essex. From I-695, take exit 34 toward Rosedale. Turn left on Philadelphia Road, Rt. 7. Go approximately 1.3miles. Immediately past Hospital Drive, turn left into the Seven Square Office Park.9106 is the building on the left.traveling south on i-95 Exit I-695 East toward Essex. From I-695, take exit 34 toward Rosedale. Turn left on Philadelphia Road, Rt. 7. Go approximately 1.3 miles.

Immediately past Hospital Drive, turn left into the Seven Square Office Park. 9106 is the building on the left.

1600 Crain Highway south, suite 601

Glen Burnie, Md 21061

traveling north on Rt. 97 Take I-97 North toward Baltimore to exit 12 toward Glen Burnie/New Cut Road. Merge onto Veterans Highway. Turn Right onto Crain Highway South. Make a u-turn at the traffic light at Oak Manor Drive andCrain Highway South. Crain Towers Office Building is on the right. traveling West on Rt. 100 Take MD-100 West to the Oakwood Road exit. Stay straight to go onto Oak Manor Road. Turn right to stay on Oak Manor Road.Turn left onto Oak Manor Drive. Make a left at the traffic light onto Crain HighwaySouth. Crain Towers Office Building is on the right.traveling east on Rt. 100 Take MD-100 East toward Glen Burnie. Merge onto I-97South, exit 13A toward Annapolis/Bay Bridge. Take Quarterfield Road, exit 13 toward Glen Burnie. Turn right onto Quarterfield Road. Turn right onto Thelma Avenue. Turn right onto Crain Highway South. Crain Towers Office Building is onthe right.traveling south on i-695 Take I-695 South toward Glen Burnie. Merge onto I-97 South, exit 4 on the left towardAnnapolis/Bay Bridge. Take Quarterfield Road, exit 13 toward Glen Burnie. Turn right on Quarterfield Road. Turn right onto Thelma Avenue. Turn right onto Crain Highway South. Crain Towers Office Building is on the right.