Patient Referral
Barry Taney, M.D. • Larry Halperin, M.D. • W. Scott Thompson, M.D.
Patrick Rubsamen, M.D. • Scott Anagnoste, M.D. • Krista Rosenberg, M.D.
Mandeep Singh Dhalla, M.D. • Kevin Kelly, M.D.
Mario del Cid, M.D. • Darin Goldman, M.D.
Patient’s Name:
Exam Date:
Referring Physician:
Diagnosis:
Ocular History:
Indicate area of concern:
OD
INSTRUCTIONS TO PATIENT:
OS
Please bring this form with you to our office.
Your eyes will be dilated and we advise that you have a driver.
You will be in our office approximately two hours. If you need a referral from your insurance plan, please be
sure to obtain one prior to your visit.
DIRECTIONS ON THE REVERSE SIDE.
Ft. Lauderdale
Imperial Point Medical Arts Pavilion
6333 N. Federal Hwy.
Suite 300
Fort Lauderdale, FL 33308
954-776-6880
Fax: 954-776-6895
Boca Raton
Boynton Beach
Glades Tower I
The 8190 Building
950 Glades Road, Suite 1-C
Boca Raton, FL 33431
561-394-6499
Fax: 561-391-6004
8190 Jog Road
Suite 250
Boynton Beach, FL 33472
561-737-1355
Fax: 561-737-8335
Directions:
Directions:
I-95 to Cypress Creek Road. Exit east to
Federal Hwy. Turn left (North) onto Federal
Hwy. and turn left again into Broward
Health Imperial Point Medical Center.
Building is on the left.
I-95 to Glades Road. Exit east to NW 10th
Avenue. Go right then a quick left into the
parking lot.
Hollywood
Directions:
I-95 to Gateway Blvd. Exit west to Jog
Road. Turn right onto Jog, then right onto
Le Chalet. Building is yellow, marked 8190,
2nd on right.
Plantation
Wellington
Presidential Circle
Bank of America Building
Bldg 1397/Medical Arts Pavilion III
Directions:
Directions:
Directions:
4000 Hollywood Blvd.
Suite 190-N
Hollywood, FL 33021
954-894-7020
Fax: 954-894-4822
1776 North Pine Island Road
Suite 312
Plantation, FL 33322
954-452-4500
Fax: 954-452-2027
I-95 to Hollywood Blvd. Exit west approx.
1 mile to Presidential Circle, 1/4 around
circle. Building on left, office is in the north
wing.
1397 Medical Park Blvd.
Suite 240
Wellington, FL 33414
561-784-3788
Fax: 561-784-3855
I-95 to Sunrise Blvd. West to Pine Island
Road. Southeast corner of Pine Island and
Sunrise Blvd.
West Palm Beach
BB&T Building
2000 Palm Bch. Lakes Blvd.
Suite 400
West Palm Bch., FL 33409
561-737-1355
Fax: 561-737-8335
Directions:
I-95 to Palm Bch. Lakes Blvd. 2 blocks west
of I-95. SW corner of Robins Dr./Palm Bch.
Lakes Blvd.
I-95 to Forest Hill Blvd. Exit west to
SR7/441. Go right then a quick left into
Wellington Regional Medical Campus. Last
bldg on NW corner.
Stuart
Eye Care and Surgery
1441 E. Ocean Blvd.
Stuart, FL 34996
561-784-3788
Fax: 561-784-3855
Directions:
I-95 to SR-76 (exit 101). Follow all the way
down to Traffic circle and take first right
which will be Ocean Blvd. Eye Care Center
will be on the left after about one mile.