To improve your experience, please complete paperwork digitally, download/print forms prior to your visit or arrive approximately 10 minutes prior to your appointment to ensure a timely appointment for yourself.

Patient Intake Form – Wallerich Eye Care – Saint Paul
Patient Intake Form – Wallerich Eye Care – Eden Prairie

Please download and print the following form to allow maximal time with your provider.

Notice of Privacy Practices

This NOTICE OF PRIVACY PRACTICES describes how we use or disclose your health information and how we can get access to such information. Please read it carefully.

Acknowledgement of Receipt of Notice of Privacy Practices

This form is required in all healthcare offices and acknowledges that you have access to, or have received a copy of the above NOTICE (per request), and that our office will not release your records or any personal information without your written consent.

Authorization to Release Medical Information

If you choose to have a doctor or staff from our office communicate with any person outside of this office, that person outside of our office must be noted on a separate singed form. The form has options for a limited time release, or open-ended (until revoked by guardian or patient).

Traumatic Brain Injury Patient Form

This form is required prior to assessing the eye and vision status post-traumatic brain injury. This is especially important for a patient involved in a Motor Vehicle Accident with a Medical Coverage rider on his or her policy. All information must be filled out completely and accurately.