%PDF-1.4
%
1 0 obj
<>>>
endobj
2 0 obj
<>stream
2020-12-16T23:13:44-05:00
2020-12-16T23:13:44-05:00
2020-12-16T23:13:44-05:00
Adobe InDesign CC 2017 (Windows)
uuid:b762eece-7795-4d56-aa25-3b9b69aecb09
xmp.did:bf3327b6-2a5c-3449-98ed-00e7c186b845
xmp.id:6e825c95-0bb2-de49-b266-73ea8b59d21d
proof:pdf
xmp.iid:8204b02a-5d57-ed48-8ff5-bd501a52b6f6
xmp.did:142ddbd1-8eec-ed44-94d5-747d8f8cc6a6
xmp.did:bf3327b6-2a5c-3449-98ed-00e7c186b845
default
converted
from application/x-indesign to application/pdf
Adobe InDesign CC 2017 (Windows)
/
2020-12-16T23:13:44-05:00
application/pdf
Adobe PDF Library 15.0
False
endstream
endobj
3 0 obj
<>
endobj
5 0 obj
<>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC/ImageI]/XObject<>>>/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>>
endobj
6 0 obj
<>stream
BT
0 0 0 1 k
/GS0 gs
/TT0 1 Tf
14 0 0 14 36.2 694.6077 Tm
(Date: ____/____/____)Tj
0 -3.62 TD
(Name: _______________________ Phone Number: ______________________\
__)Tj
/TT1 1 Tf
0 1.577 TD
(Patient Information:)Tj
ET
q
132.2 721.483 347.999 32.116 re
W n
q
/GS1 gs
347.9999803 0 0 32.1166582 132.1999969 721.4833174 cm
/Im0 Do
Q
Q
q
0 0 612 792 re
W n
0 0 0 1 K
4 M
q 1 0 0 1 191.6 357.7 cm
0 0 m
39.157 0 70.9 34.161 70.9 76.3 c
70.9 118.439 39.157 152.6 0 152.6 c
-39.157 152.6 -70.9 118.439 -70.9 76.3 c
-70.9 34.161 -39.157 0 0 0 c
h
S
Q
q 1 0 0 1 190.6197 377.95 cm
0 0 m
29.337 0 53.12 25.598 53.12 57.175 c
53.12 88.752 29.337 114.35 0 114.35 c
-29.337 114.35 -53.12 88.752 -53.12 57.175 c
-53.12 25.598 -29.337 0 0 0 c
h
S
Q
Q
0 0 0 1 K
4 M
q 1 0 0 1 236.1137 506.5115 cm
0 0 m
-15.984 -23.475 l
S
Q
q 1 0 0 1 156.2844 390.5912 cm
0 0 m
-15.871 -23.31 l
S
Q
q 1 0 0 1 243.3266 434.654 cm
0 0 m
30.673 0 l
S
Q
q 1 0 0 1 107.3266 434.22 cm
0 0 m
30.673 0 l
S
Q
q 1 0 0 1 143.9697 506.4295 cm
0 0 m
15.592 -24.24 l
S
Q
q 1 0 0 1 220.324 387.8712 cm
0 0 m
15.255 -23.717 l
S
Q
q 1 0 0 1 191.5 520.6 cm
0 0 m
0 -28.4 l
S
Q
q 1 0 0 1 191.88 378.2 cm
0 0 m
0 -28.2 l
S
Q
q 1 0 0 1 117.9495 476.2794 cm
0 0 m
25.399 -14.37 l
S
Q
q 1 0 0 1 237.2579 408.7623 cm
0 0 m
24.544 -13.886 l
S
Q
q 1 0 0 1 117.1952 396.3423 cm
0 0 m
25.585 14.036 l
S
Q
q 1 0 0 1 237.3903 462.2681 cm
0 0 m
24.724 13.564 l
S
Q
q
0 0 612 792 re
W n
q 1 0 0 1 182.907 456.5315 cm
0 0 m
-2.028 -0.144 -3.979 -0.51 -5.817 -1.07 c
S
Q
q 1 0 0 1 184.85 419.5 cm
0 0 m
12.399 0 22.45 8.305 22.45 18.55 c
22.45 28.795 12.399 37.1 0 37.1 c
-0.655 37.1 -1.303 37.077 -1.943 37.031 c
S
Q
q 1 0 0 1 177.0894 420.6382 cm
0 0 m
2.419 -0.736 5.033 -1.138 7.761 -1.138 c
S
Q
q 1 0 0 1 220.1005 454.3214 cm
0 0 m
-8.36 -3.966 -13.487 -11.932 -12.064 -20.003 c
-11.139 -25.25 -7.629 -29.507 -2.755 -32.083 c
S
Q
q 1 0 0 1 207.75 435.4 cm
0 0 m
1.464 0 2.65 1.186 2.65 2.65 c
2.65 4.114 1.464 5.3 0 5.3 c
-1.464 5.3 -2.65 4.114 -2.65 2.65 c
-2.65 1.186 -1.464 0 0 0 c
h
S
Q
Q
BT
14 0 0 14 35.8 300.2076 Tm
(Referring Physician Information:)Tj
ET
0 0 0 0 k
/GS1 gs
36 268.4 231.6 19.2 re
f
BT
0 0 0 1 k
/GS0 gs
/TT0 1 Tf
14 0 0 14 36 277.4076 Tm
(Name: _______________________)Tj
/C2_0 1 Tf
0 -1.671 TD
<00321088004600480003003100580050004500480055001D00030042004200420042004200420042004200420042004200420042004200420042>Tj
/TT0 1 Tf
0 -1.657 TD
(Appointment Date: ____/____/____)Tj
-0.018 Tw 0 -1.714 TD
[(Appointment T)37.3 (ime: )-18 (_____________)]TJ
/TT1 1 Tf
0 Tw 17.729 6.679 Td
[(Appointment W)9.6 (ith:)]TJ
/C2_1 1 Tf
-15.072 -9.15 Td
<0033004F0048004400560048000300460044004F004F000300570052000300560046004B004800470058004F004800030044005100030044005300530052004C005100570050004800510057000F00030057004B00480051000300490044005B00030057005200030044005300530055005200530055004C004400570048000300521088004600480011>Tj
/TT0 1 Tf
11 0 0 11 297.2 273.9917 Tm
[(Mark )55.2 (A. Gersman, MD)]TJ
-0.055 -2.091 Td
[(Robert E. W)18.3 (enz, MD)]TJ
0 -2 TD
(Stephen R. Kaufman, MD)Tj
/C2_0 1 Tf
0 -2.055 TD
[<003000440055004600030029>111 <0011002A001100030028005600570044004900440051005200580056000F000300300027>]TJ
13.673 6.164 Td
<003600520053004B004C00440003002C00110003003300440046004B005C00470044004E004C000F000300300027>Tj
/TT0 1 Tf
0.018 -2.145 Td
(Stephen M. Conti, MD)Tj
/C2_0 1 Tf
-0.018 -1.945 Td
[<0035004C0046004B0044005500470003002800110003003A>8.6 <005C0056005D005C00510056004E004C000F000300300027>]TJ
/T1_0 1 Tf
18 0 0 18 415.4 326.9142 Tm
(OS)Tj
/TT1 1 Tf
14 0 0 14 36.2 597.4077 Tm
(Referring Diagnosis:)Tj
/TT0 1 Tf
10.314 0 Td
( OD OS OU __________________________________)Tj
/T1_0 1 Tf
-0.013 Tc 0.013 Tw 18 0 0 18 177.8 327.7142 Tm
(OD)Tj
ET
285 274.5 6.2 6.2 re
S
285 251.5 6.2 6.2 re
S
284.9 229.18 6.2 6.2 re
S
284.7 206.5 6.2 6.2 re
S
435.28 275 6.2 6.2 re
S
435.28 252 6.2 6.2 re
S
435.28 230.18 6.2 6.2 re
S
q
0 0 612 792 re
W n
q 1 0 0 1 429.3266 357.7 cm
0 0 m
-39.157 0 -70.9 34.161 -70.9 76.3 c
-70.9 118.439 -39.157 152.6 0 152.6 c
39.157 152.6 70.9 118.439 70.9 76.3 c
70.9 34.161 39.157 0 0 0 c
h
S
Q
q 1 0 0 1 430.3069 377.95 cm
0 0 m
-29.337 0 -53.12 25.598 -53.12 57.175 c
-53.12 88.752 -29.337 114.35 0 114.35 c
29.337 114.35 53.12 88.752 53.12 57.175 c
53.12 25.598 29.337 0 0 0 c
h
S
Q
Q
q 1 0 0 1 384.8128 506.5115 cm
0 0 m
15.984 -23.475 l
S
Q
q 1 0 0 1 464.6422 390.5912 cm
0 0 m
15.871 -23.31 l
S
Q
q 1 0 0 1 377.6 434.654 cm
0 0 m
-30.673 0 l
S
Q
q 1 0 0 1 513.6 434.22 cm
0 0 m
-30.673 0 l
S
Q
q 1 0 0 1 476.9569 506.4295 cm
0 0 m
-15.592 -24.24 l
S
Q
q 1 0 0 1 400.6026 387.8712 cm
0 0 m
-15.255 -23.717 l
S
Q
q 1 0 0 1 429.4265 520.6 cm
0 0 m
0 -28.4 l
S
Q
q 1 0 0 1 429.0465 378.2 cm
0 0 m
0 -28.2 l
S
Q
q 1 0 0 1 502.9771 476.2794 cm
0 0 m
-25.399 -14.37 l
S
Q
q 1 0 0 1 383.6687 408.7623 cm
0 0 m
-24.544 -13.886 l
S
Q
q 1 0 0 1 503.7314 396.3423 cm
0 0 m
-25.585 14.036 l
S
Q
q 1 0 0 1 383.5363 462.2681 cm
0 0 m
-24.724 13.564 l
S
Q
q
0 0 612 792 re
W n
q 1 0 0 1 438.0196 456.5315 cm
0 0 m
2.028 -0.144 3.979 -0.51 5.817 -1.07 c
S
Q
q 1 0 0 1 436.0766 419.5 cm
0 0 m
-12.399 0 -22.45 8.305 -22.45 18.55 c
-22.45 28.795 -12.399 37.1 0 37.1 c
0.655 37.1 1.303 37.077 1.943 37.031 c
S
Q
q 1 0 0 1 443.8372 420.6382 cm
0 0 m
-2.419 -0.736 -5.033 -1.138 -7.761 -1.138 c
S
Q
q 1 0 0 1 400.8261 454.3214 cm
0 0 m
8.36 -3.966 13.487 -11.932 12.064 -20.003 c
11.139 -25.25 7.629 -29.507 2.755 -32.083 c
S
Q
q 1 0 0 1 413.1766 435.4 cm
0 0 m
-1.464 0 -2.65 1.186 -2.65 2.65 c
-2.65 4.114 -1.464 5.3 0 5.3 c
1.464 5.3 2.65 4.114 2.65 2.65 c
2.65 1.186 1.464 0 0 0 c
h
S
Q
Q
0 0 0 0 k
/GS1 gs
257.16 195.62 23 90.7 re
f
BT
0 0 0 1 k
/GS0 gs
/TT0 1 Tf
0 Tc -0.055 Tw 11 0 0 11 47.2 575.1917 Tm
[(W)18.2 (et AMD)]TJ
/C2_0 1 Tf
0 Tw 0 -1.364 TD
[<00270055005C0003>55.2 <002400300027>]TJ
/TT0 1 Tf
0 -1.364 TD
(Nevus/Melanoma)Tj
/C2_0 1 Tf
0 -1.364 TD
<0026004400570044005500440046005700030026004F0048004400550044005100460048>Tj
10.945 4.109 Td
[<003300520056005700480055004C0052005500030039>17.8 <004C005700550048005200580056000300270048005700440046004B0050004800510057>]TJ
/TT0 1 Tf
-0.018 Tw 0 -1.364 TD
[(Retinal )-0.6 (T)111 (ear)]TJ
/C2_0 1 Tf
0 Tw 0 -1.364 TD
<003500480057004C00510044004F000300270048005700440046004B0050004800510057>Tj
T*
<003300480055004C0053004B004800550044004F0003002B0052004F00480012002F004400570057004C0046>Tj
/TT0 1 Tf
9.561 0 Td
(e)Tj
/C2_0 1 Tf
6.212 4.073 Td
[<00240055005700480055005C00120039>55.4 <0048004C00510003003200460046004F00580056004C00520051>]TJ
T*
<0030004400460058004F00440055000300280047004800500044>Tj
0 -1.364 TD
<0030004400460058004F004400550003002B0052004F0048>Tj
/TT0 1 Tf
0 -1.364 TD
(Epiretinal Membrane)Tj
/C2_0 1 Tf
12.245 4.109 Td
<0027004C0044004500480057004C00460003003500480057004C00510052005300440057004B005C>Tj
/TT0 1 Tf
0 -1.364 TD
(Uveitis)Tj
/C2_0 1 Tf
0 -1.364 TD
<0027004C00560046000300280047004800500044>Tj
/TT0 1 Tf
T*
(Plaquenil Use)Tj
ET
37.8 576.1 6.2 6.2 re
S
158.9 576.1 6.2 6.2 re
S
331.35 576.1 6.2 6.2 re
S
466.45 576.1 6.2 6.2 re
S
37.8 561.1 6.2 6.2 re
S
158.9 561.1 6.2 6.2 re
S
331.35 561.1 6.2 6.2 re
S
466.45 561.1 6.2 6.2 re
S
37.8 546.68 6.2 6.2 re
S
158.9 546.78 6.2 6.2 re
S
331.25 546.78 6.2 6.2 re
S
466.35 546.78 6.2 6.2 re
S
37.8 532.26 6.2 6.2 re
S
158.9 531.78 6.2 6.2 re
S
331.35 531.78 6.2 6.2 re
S
466.45 531.78 6.2 6.2 re
S
BT
14 0 0 14 36.2 620.9077 Tm
(Date of Birth: ____/____/____)Tj
/TT1 1 Tf
17.598 -36.579 Td
(Mentor)Tj
/C2_0 1 Tf
12 0 0 12 178.3061 87.8637 Tm
[<001B001400170013000300310052005500570052005100030033004E005A005C>73.3 <0011000F000300360057004800110003001500160013000F0003003000480051005700520055>55.6 <000F00030032002B000300170017001300190013>]TJ
0.876 -1.233 Td
<0033004B005200510048001D0003001B00130013001000150015001900100014001A0016001B0003000300030003000300290044005B001D00030017001700130010001C0014001B0010001A001700170013>Tj
ET
q 1 0 0 1 313.5574 80.6929 cm
0 0 m
-3.536 -3.536 l
0 -7.071 l
3.536 -3.536 l
h
f
Q
q 1 0 0 1 313.5574 80.6929 cm
0 0 m
-3.536 -3.536 l
0 -7.071 l
3.536 -3.536 l
0 0 l
h
S
Q
endstream
endobj
15 0 obj
<>stream
#,4C\o½kXA3-&
9fܯ~Q.
*lզqB
$>Oc7
Bx9 +