Eye Care Provider Referral Form

"*" indicates required fields

Patient First Name*

Patient Last Name*

Address*

Street Address City State ZIP Code

Phone*

Date of Birth*

Gender

Patient Insurance*

Referring Physician*

Reason for Referral*

Referring Provider Name

Clinic Name

Clinic Phone Number

Interpreter Needed

Yes

Which language?

Please include a copy of most recent exam notes and fax to 651-251-5950

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Open Cities Health Center

We’re here to help you live your healthiest, happiest life.

Dunlap Clinic

409 North Dunlap St.
St. Paul, MN 55104

HOURS
MWTHF: 8am – 5pm
Tuesdays: 8am – 8pm

North End Clinic

916 Rice St.
St. Paul, MN 55117

HOURS
Monday – Friday: 8am – 5pm

Health Services

About Us

Open Cities Health Center is a FTCA deemed Facility.

This health center receives HHS funding and has Federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.