NEW PATIENTS – FORMS
Thank you for choosing Wallerich Eye Care. Please plan to arrive approximately 10 minutes prior to your appointment time. After you schedule your appointment, you will receive your “New Patient Forms” via text/email for you to complete electronically. We ask that you complete your “New Patient Form” prior to your visit. Please fill out the form to the best of your ability, as it is our goal to provide the best eye and vision care possible!
1. Electronic Form
CLINIC INTAKE FORM
2A. Download/ Paper Copy (English)
If you are unable to complete your “New Patient Form” electronically, please download/print or arrive early to complete in office.
SAINT PAUL INTAKE FORM DOWNLOAD
EDEN PRAIRIE INTAKE FORM DOWNLOAD
2B. Descargar el formulario (Español)
Si no puede completar su “Formulario de Paciente Nuevo” electrónicamente, descárguelo e imprímalo o llegue temprano para completarlo en la oficina.
What should you expect while in the office?
Whether you are new to our practice, an established patient, or this is your very first eye exam, we look forward to your visit with us. You can expect your optometry technician and your eye doctor to ask the following:
- Medical history (medications, medical history, past surgeries, etc.)
- Eye/Vision history (eye drops, history of eye surgeries, etc.)
Please bring all the following:
- Most Recent Glasses
- Sunglasses (if prescription)
- Contact Lens Boxes
- Any eye drops you are using
- A list of all prescription medications you take
MEDICAL RECORDS REQUEST
Medical Record Request – NEW Patients
If you are new to our practice, feel free to complete a medical release form to send to your prior eye doctor’s office.
Medical Record Request – EXISTING Patients
If you would like a copy of your medical record and/or would like us to release your medical records to a physician/facility, please download and print our Medical Records Release Form. After you complete and sign the form, please send it to us by mail, fax, email, or in-person.
- Attention Optical
- Wallerich Eye Care
- 1300 University Ave W
- Saint Paul, MN 55104
Fax: (612) 299-1452
NOTICE OF MEDICAL PRIVACY INFORMATION
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.