Valencia Office - California Retina

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Keywords

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Transcript

Briefly state the reason for the referral.
* If the patient has an HMO and this is the first time they are seeing us, you will
need to get a authorization from the patients PCP before the patient can see us.
Valencia Office
27420 Tourney Rd
Suite 170
Valencia, CA 91365
(661) 253-2939
Patient: Patient's Phone#
Date of Appointment: Time:
Referring Physician:
Phone: Fax:
Insurance:
Suite
170
E
S
W
N
To Los Angeles
To San
FranciscoI-5 G
olden State H
w y Magic Mountain Pkwy
McBean Pkwy
Valencia Blvd.
Tourney R
d. Robert L. Avery, M.D. Ma'an A. Nasir, M.D. Dante J. Pieramici, M.D. Alessandro A. Castellarin, M.D.
Robert F. See, M.D. Stephen S. Couvillion, M.D. Nathan C. Steinle, M.D Dilsher S. Dhoot, M.D.
Fill out here and then print or print out and fill in

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