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Online Patient Forms

Thank you for choosing Wallerich Eye Care for your eye and vision needs! We look forward to seeing you!

Please click New Patient to complete the following TABs to the best of your ability. We do make every attempt to determine eligibility and benefits for your vision and medical benefits prior to your appointment; however, we make no guarantee of coverage, as your insurance ultimately makes the final determination.

Please add as much information as possible to help us provide a seamless experience in the office!

Please complete the online forms, before your first office visit.

Existing Patients


• Text/Call Wallerich Eye Care with questions: (612) 723-9895
• Email Wallerich Eye Care at OM@wallericheyecare.com